eHealth in Action

Good Practice
inEuropean Countries

Good eHealth Report

January 2009
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eHealth in Action
Good Practice
in European Countries
Good eHealth Report
January 2009
 Acknowledgements
This report was prepared by the Good eHealth team The Good eHealth team also owes a great debt to all
on behalf of the European Commission, Directorate- the national correspondents and case owners who
General Information Society and Media.We thank our contributed to the project. Without their strong sup-
colleagues from the ICT for Health Unit for their kind port this report would not have been possible.
support. In particular, we are grateful to Gérard Of course, possible inaccuracies of information are at
Comyn, Head of Unit and Ilias Iakovidis, Deputy Head the responsibility of the project team. This report
of Unit, for their guidance and promotion of this acti- reflects solely the views of its authors.
vity, to our Project Officers Michael Palmer and
Octavian Purcarea, for their enthusiastic commitment
to our work as well as for their valuable contribution;
and to Corinne Wenner, Information and Commu-
nication Officer for her great help in finalising this
report.

... 2
Foreword
European Research and Development ‘Framework
Programmes’ have been supporting innovative informa-
tion and communication technologies to facilitate and
improve the delivery of health services (ICT for Health
or eHealth) for more than 20 years.This has resulted in over
450 projects worth more than € 1 billion, thus contribut-
ing to the emergence of standardised eHealth solutions such
as electronic health record systems and a health knowledge
infostructure across Union member states.
Since 2004, the EC has also taken a lead in coordinating
eHealth policy development and applications deployment
by adopting a European eHealth Action plan. Almost all
member states have identified within their information soci-
ety policies or, more specifically, as part of their health
policy priorities, the fostering of eHealth implementa-
tions as a key priority to help meet the challenges which
all our health systems face.
By now it has become a commonly accepted health poli-
cy premise that,without the wider adoption of eHealth solu-
tions, national and regional health systems will not be
able to cope with the steadily rising demands for better health
services and the cost impact of medico-technical progress
which allows us to achieve a healthier and longer life for our
citizens.And it will foster the further growth of the European
eHealth industry and its competitiveness in an emerging
global eHealth market,identified as an innovation-friend-
ly market by the recent EC Lead Market Initiative.
But what is the current situation? Where is “eHealth in
Action”? Already the 2004 Action Plan envisaged that draw-
ing on and sharing best practices and experience from across
the Union would enable Europe to move towards a“European
eHealth Area”. Indeed,“sharing best practices and meas-
uring progress”is one of the three target areas of this Plan.
It is in this spirit that this publication (and the knowledge
base on which it builds) disseminates and shares best prac-
tice across all member states. It clearly documents that
eHealth has become a routine tool in the daily praxis of many
healthcare providers and has proven its usefulness in a wide
variety of application fields.ICT solutions supporting core
activities of the healthcare process like diagnosis, therapy
or rehabilitation are supplemented by solutions for con-
tinued medical education or facilities management and
logistics. Health promotion websites, comprehensive in-
house hospital information systems or cross-border health
services, teleconsultation or remote monitoring of chron-
ically ill are further examples of advanced eHealth solutions.
And the vast opportunities for clinical research and tri-
als, training or public health must not be overlooked.
However, to meet European health policy goals and pri-
orities and further develop the ‘European Social Model’,
many more healthcare providers must follow these early
innovators. Learning and knowledge exchange are key to
this, but not yet common practice across the fragmented
landscape of Europe’s health systems. A thorough analy-
sis of differences and similarities, successes and chal-
lenges will make the difference. The wealth of experiences
presented in this booklet will support such learning process-
es and enable all stakeholders in the health services sec-
tor to get inspired by its treasure of ideas.
An important lesson to be drawn from the eHealth solu-
tions presented is that eHealth has not only proven its
usefulness but also its sustainability. Some of the solu-
tions already benefit from close to ten years of experi-
ence.Several of them have initially been funded as pilots by
various support programmes of the European Commission.
And this experience and the lessons learned will diffuse fur-
ther and faster, as eHealth delivers more and more bene-
fits to all stakeholders: patients, consumers, health
professionals, healthcare organisations, third party pay-
ers and society as a whole.
The ‘Good eHealth’ study, which developed a compre-
hensive data base, has been a key element of the eHealth
Action Plan initiatives of the European Commission to fos-
ter the Union-wide exchange of eHealth best practice. In
a wider eGovernment context,this work will be followed up
by ‘ePractice.eu’ in the years to come. With these initia-
tives we encourage all eHealth stakeholders to further devel-
op innovative ideas and exchange their experience and
knowledge with the European health services and policy
communities for the benefit of a healthier Europe.
Brussels, January 2009
Gérard Comyn
Head of Unit ICT for Health
European Commission, Directorate General
Information Society and Media 3 ...
 About Good eHealth
and this report
Good eHealth – Exchange of Good Practices in eHealth
– is a three-year study (2006-2008) funded under the for-
mer Modinis programme by the Directorate-General
Information Society and Media.The objectives of this
study are to:
X identify good practices and
their associated benefits
X develop and implement proven approaches to wider
dissemination and transfer real-life experiences
X stimulate accelerated take-up of eHealth
by addressing common implementation
challenges and lessons learned.
This report presents case studies from 30 European coun-
tries for which validated information was available to the
project by the end of November 2008. This informa-
tion reflects the situation of the cases at the date of
delivery to the project by national correspondents during
the time period 2006-2008. Possible inaccuracies and
subjectiveness of information are the responsibility of
the project team.This report solely reflects the views
of its authors.
The report is the outcome of research in the context
of the Good eHealth project, implemented in coope-
ration between Deloitte Belgium and empirica
Communication and Technology Research, Germany.
The Good eHealth project is commissioned by the
European Commission, DG Information Society and
Media, ICT for Health Unit.

Deloitte Belgium Gesellschaft für Kommunikations- und

Pegasus Park Technologieforschung mbH
Berkenlaan 8bB Oxfordstr. 2
1831 Diegem 53111 Bonn
Belgium Germany
info@good-ehealth.org info@good-ehealth.org

Good Practice Knowledge Base = www.good-ehealth.org

... 4 The European Commission is not liable for any use that may be made of the information contained therein.
Table of contents
Acknowledgements 2
Foreword 3
Good eHealth practice - adding value to health services 6

Good eHealth practice in European Countries 11

Austria 13
Belgium 14
Bulgaria 16
Cyprus 17
Czech Republic 18
Denmark 19
Estonia 21
Finland 22
France 23
Germany 25
Greece 27
Hungary 29
Ireland 30
Italy 31
Latvia 33
Lithuania 34
Luxembourg 35
Malta 36
Netherlands 37
Norway 39
Poland 40
Portugal 41
Romania 43
Slovakia 45
Slovenia 46
Spain 47
Sweden 49
Switzerland 52
Turkey 54
United Kingdom 55
5 ...
 Good eHealth practice -
adding value
to health services
KARL A. STROETMANN, REINHARD HAMMERSCHMIDT, VELI N. STROETMANN, INGRID MOLDENAERS
This booklet presents 30 summary case studies from 30
European countries, and many more abstracts of addi-
tional cases, all of them described in detail in the eHealth
Good Practice Knowledge Base (www.good-ehealth.org).
But why is it worth spending resources on identifying,
recording and analysing such cases? And what is the
wider context within which such efforts must be seen?
These are among the issues to be briefly discussed in this
introductory chapter, which will also reflect on the rele-
vance and beneficial impact of eHealth applications on
health policy priorities and health system challenges.
This will be complemented by a short summary analysis
of cases presented in this publication and in the online
knowledge base, including a concise review of success
factors identified in these cases. As we underline in the
Outlook section, this is ‘work in progress’, to be continued
in the years to come.
Why presenting good practice cases?
Sharing and disseminating “best practices”, including
measuring progress, is one of three target areas men-
tioned in the 2004 eHealth Action Plan of the European
Commission.1 “Drawing on best practices and experi-
ence from across the Union” is expected to facilitate the
move towards a “European eHealth Area” and the devel-
opment of common approaches to shared problems over
time. 2 Spreading best practices is a means to support
Member States, policy makers and other actors in the
health system in their efforts to address common chal-
lenges and create the right framework to accelerate
eHealth implementation and diffusion for the benefit of
all citizens. "Learning from each other is not a natural
behaviour in the fragmented landscape of European health
delivery systems. Taking the time to understand the success
factors and the mistakes of others can tip the balance
towards better health services through innovative eHealth
solutions and thus avoid a waste of scarce resources”, com-
mented Ilias Iakovidis, Deputy Head of the European
Commission’s ICT for Health Unit.
... 6
Documenting good practice
DEFINING A GOOD PRACTICE CASE
Case studies come in a wide variety of types, from short
cursory notes to book-length descriptions compiled after
months and years of information gathering, observation
of and sometimes even direct participation in work
processes.3 For our research, we relied on an approach
based on a structured “single case design” 4, focusing on a
single unit of analysis, which may be a specific eHealth
application or system, but also a regional network or sim-
ilar "unit".
For our purposes, we defined a good practice case as a real
life, sustained eHealth solution in routine operation,
which represents a good learning experience for Europe
or for the country / region concerned, though not neces-
sarily an ideal solution or one without any problems.
We prefer to talk about good practice only: there does not
exist ‘best’ practice as a generic concept across disparate
health services systems.What is judged as ‘best’will always
depend on the national, cultural, structural context and
subjective assessments. What might be judged by some as
best in one context may not be applicable at all in another,
even similar context or not "work" for other reasons like
legal requirements or habits and attitudes of citizens. On
the other hand, good practice cases as defined above - in
spite of reflecting unique experiences - can provide useful
insights for others, likely to stimulate creativity, self-
reflection and the transfer or adaptation of good ideas.
It must be noted that the above definition excludes a wide
variety of "cases" quite often regarded as good practice,
like experimental or pilot implementations, initial deploy-
ment situations and the like. Experience has shown that
many of such applications are not sustainable once the
research and development (R&D) or start-up funding has
ended.
1. COM (2004) 356, Communication from the Commission to the Council, the European Parliament, the
European Economic and Social Committee and the Committee of the Regions – eHealth: making health
care better for European citizens – An action plan for a European eHealth Area.
eHealth action plan: http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=COM:2004:0356:FIN:EN:PDF
2. Ibidem, p. 4
3. On the latter type, see, e.g., some of the papers on organisational change in industry, particularly in
Volume III, in David Preece, Ian McLaughlin, Patrick Dawson (eds.):Technology, Organizations and
Innovation - Critical Perspectives. Four volumes, New York: Routledge 2000.
4. Yin, Robert K. (2003): Case Study Research. Design and Methods. In: Applied Social Research Methods
Series Volume 5., Southand Oaks: Sage Publications, p. 34.
FROM IDENTIFICATION
TO FINAL CASE DESCRIPTION
The identification of sustained eHealth solutions is the
first step in the research process of Good eHealth. Initially,
the project started re-investigating eHealth collections
available from earlier studies like eHealth Impact 5 or the
applications submitted to the eEurope Awards 2003 to
2005 6. To identify further cases, which had not yet been
presented in an international context before, the project
initiated a network of country correspondents, who are
familiar with the national, regional or local market and
are able to speak the country’s language. Thus continu-
ously observing the eHealth situation, the project
screened more than 600 eHealth solutions.
A Good eHealth internal selection board reviews all cases
identified and agrees on a final list of cases for further
investigation. This selection process is based on the
expert knowledge of the board members and is guided by
a set of criteria. These include the track record of the
respective case, the geographic balance of countries and
the types of solutions, the degree of innovativeness as
well as the likely commitment of the health service
provider to make further information available. The
number of proposed cases exceeded the number of cases
eventually included in the knowledge base. A limited
cooperation of the ‘case owners’, language problems and
other constraints, explain this difference. And, of course,
considering this selection process, the cases cannot be
regarded as a representative sample of European ‘reality’
nor assessed ‘objectively’ as the best ones to be found
across Europe.
A selected case is then investigated in some depth.
Secondary sources, published and unpublished material
and telephone interviews with stakeholders are used.
Country correspondents are again active in this process.
As native speakers they can communicate most effective-
ly with the case owner. The country correspondents
deliver their output back to the project team, which
assesses the case’s quality and publishes it in the online
knowledge base.
5. www.ehealth-impact.org
6. www.e-europeawards.org
IMBEDDING GOOD PRACTICE
IN A GLOBAL LEARNING ENVIRONMENT
The importance of learning from good practice has been
acknowledged not only across Europe, but also globally.
The Canadian Society of Telehealth for example provides
an online Telehealth Resource Kit with a variety of change
management case studies as part of its Telehealth Change
Management Repository.7
Recently, the US Agency for Healthcare Research and
Quality noted that “successful examples [of health infor-
mation technology] are few and inconsistent. ... To gener-
ate substantial and ongoing improvements in care, health
IT adoption must go hand in hand with ... the routine use
of solid improvement methods by clinicians and other
staff.” 8 Well organised good practice repositories should
be part of this effort. The agency also recognised the need
for “a national database of actual results of EMR
[Electronic Medical Records] implementations using
common terms, definitions and metrics, along with sup-
porting information about the environment that pro-
duced those results”.9
eHealth in support
of European health systems
But why is learning from each other and exchanging
experience about eHealth implementations so important
across Member States? It is because evidence is accumu-
lating10 that eHealth can indeed help societies to cope
with the challenges for European health systems. Solidly
financed healthcare systems are an essential part of the
European social model, the right to high quality health-
care is a material expression of European citizenship.11
7. http://www.cst-sct.org/cm/
8. Langley J, Beasley C.Health Information Technology for Improving Quality of Care in Primary Care Settings.
Prepared by the Institute for Healthcare Improvement for the National Opinion Research Center under
contract No.290-04-0016.AHRQ Publication No.07-0079-EF.Rockville, MD:Agency for Healthcare Research
and Quality.July 2007, p.1.
9. Douglas I.Thompson et al.A review of methods to estimate the benefits of Electronic Medical Records in
hospitals and the need for a national benefits database.Journal of Healthcare Information Management,Vol.
21 (2007), No.1, p.66.
10. Cf., e.g., European Commission (ed) (2006):eHealth is Worth it - The economic benefits of implemented
eHealth solutions at ten European sites.Luxembourg:Office for Official Publications of the European
Communities (OPOCE). http://ec.europa.eu/information_society/activities/health/docs/publications/eheal-
thimpactsept2006.pdf
Economic impact of interoperable electronic health records and ePrescription in Europe (www.ehr-impact.eu)
11. Kickbusch I (2005) The Health Society:Importance of the new policy proposal by the EU Commission on
Health and Consumer Affairs, Health Promotion International 20(2):101-103; Sindbjerg-Martinsen D (2005)
Towards an Internal Health Market with the European Court,West European Politics 28(5):1035-1056. 7 ...
 Good eHealth practice -
adding value
to health services
However, medico-technical, socio-economic and health
system trends challenge the successful pursuit of these
values.“Roughly half of the increase in health care spend-
ing during the past several decades was associated with
the expanded capabilities of medicine brought about by
technological advances.”12 It feeds on the average age of
the population, i.e. life expectancy at birth increases and
the elderly fraction of the population grows. The demo-
graphic change caused by these advances, the ageing of
our societies, in turn affects both the clinical pattern -
driving demand for health services - and the available
resources for healthcare - enabling supply. And eHealth
applications have proven their potential to become key
means in support of meeting such challenges They can
open up new opportunities for the further development
of our health systems.
eHealth good practice – the evidence
SHOWCASING A WIDE VARIETY OF SOLUTIONS
As the manifold cases in this booklet and in the Good
eHealth knowledge base demonstrate, eHealth comes in a
wide variety of solutions, and can support all types of
health services: health promotion, diagnosis, therapy,
rehabilitation or long-term care. eHealth can also under-
pin support activities like management and administra-
tion, logistics and supply of health-related goods,
facilities management as well as public health, continued
medical education, or medical research and clinical trials.
All theses activities rely on the exchange of information
and communication with each other. eHealth solutions
facilitate this across wards and departments as well as the
wide range of actors, stakeholders and institutions com-
posing regional, national or cross-border European
health value systems.
In its 2007 report on ‘eHealth priorities and strategies in
European countries’, the European Commission present-
ed governments’ plans and undertakings with respect to
eHealth policies, strategies, roadmaps, and infrastruc-
tures on a national level.13
In a complementary fashion, this booklet focuses on the
diversity of implemented eHealth solutions in European
... 8 countries – from implementations at a ward up to nation-
wide level, and cross-border activities. The Good eHealth
case descriptions of about 100 successful solutions in
routine operation showcase important examples of the
diversity of eHealth practice in Europe.14 They can, for
example, be implemented at various levels of a single
organisation, between several organisations, and at a
regional, national or international level. The knowledge
base usage statistics show a particular interest of users for
single-site und inter-organisational case studies.
Good eHealth in figures
In general, available eHealth solutions can facilitate any
primary as well as support activity of the healthcare value
chain within a single organisation.15 They either offer a
specific functionality or support in an integrative fashion
several connected activities. About half of all cases in the
database deal with or are also connected to health admin-
istration and management tasks, i.e. so-called support
activities. The other share of cases deals with applications
supporting or connected to therapy, then diagnosis -
both less than one-third, and health promotion with
about one-fifth. The reason for administration and man-
agement solutions being so prevalent is probably the very
nature of IT systems: they deliver relatively early measur-
able benefits when applied to well-structured processes,
which is a key concern for many healthcare providers.
The diagnostic and treatment processes, on the other
hand, are more difficult to structure, but are in essence
the primary activities of health service provision. In
addition, knowledge base users show increasing interest
in areas not related to direct patient care but to the re-use
of such information for research, training or manage-
ment purposes.
Analysing the overall set of cases in some more detail, the
term ‘hospital’ appears in three-fourths of them, indicat-
12. The Congress of the United States, Congressional Budget Office (CBO):Technological Change and the
Growth of Health Care Spending.Washington, DC, January 2008, p. 12.Technological advances is there
defined as “changes in clinical practice that enhance the ability of providers to diagnose, treat, or prevent
health problems.”
13. European Commission (ed) (2007): eHealth priorities and strategies in European countries. Luxembourg:
Office for Official Publications of the European Communities (OPOCE)
http://ec.europa.eu/information_society/activities/health/docs/policy/ehealth-era-full-report.pdf.
14. www.good-ehealth.org
15. On these concepts, see Porter, Michael E. (1985): Competitive advantage. New York:The Free Press, p. 36ff.
ing that their great majority is connected in one way or
another to hospital-related activities. In contrast, the
acronym GP or term ‘general practitioner’ is recorded in
only one-third. Telemedicine and telecare are mentioned
in 25 percent of the documents, subsets of which refer to
home monitoring half the time and only few to telecon-
sultation or teleradiology. Electronic health record (EHR)
systems are mentioned in 25 percent of the cases, picture
archiving and communication systems (PACS) in about
10 percent, and ePrescribing in 7 percent.About one-fifth
of cases refer to some type of ‘cards’.
The cases with the longest experience included in the
knowledge base were planned in the early 1990s. In 1994,
the first cases started routine operation. While the data-
base includes 21 cases with more than eight years of
experience, most of the cases started routine operation
between 2001 and 2006, indicating that eHealth is becom-
ing more and more a routine part of healthcare. The
interest of viewers of the knowledge base spreads evenly
across all documents, not indicating a specific preference
for older or newer cases.
All of these data exemplify the comprehensiveness of the
variety of cases documented, but they can in no way be
constructed as being representative for the European
Union. On the following pages, the Good eHealth project
presents case studies selected from the ones recorded in
the knowledge base. This selection underlines this width
of solutions and does not necessarily identify those
which may be judged by some as most important, suc-
cessful or interesting. Such an assessment would anyhow
always vary depending on the purpose at hand. The suc-
cess factors which determine the sustainability of the
eHealth cases and lessons learned are presented in the
following section.
Success factors and lessons learned
In the course of researching the Good eHealth cases,
executives and innovation champions responsible for
realising the application in the respective organisation
were asked to inform about success factors and lessons
learned. Solutions are considered to be successful when
they turned out to be sustainable in the longer term.16
Project managers and users from various backgrounds
described the success of their eHealth solutions mostly in
the way ‘how’ the respective solution was implemented
and did not relate success much to ‘what’ was implement-
ed. The major success factor was securing acceptance
within the organisation through the adoption of change
management processes. Acceptance starts with a sound
analysis of users’ requirements at the outset of an imple-
mentation project. Project managers emphasised that all
stakeholders affected should be included in such an
analysis. Furthermore, continuous involvement of the
stakeholders during the whole development and imple-
mentation life cycle must be assured. Medical profession-
als turned out to be a crucial stakeholder group that
needs to agree. Stakeholder feedback must be taken seri-
ously to create trust. Other important stakeholders are
patients. This implies, among other things, that decision
makers should not confuse user-centred design with
health professional centred design.
Of course, achieving trust and agreement is not always
easy. When it comes to changes in an organisation, con-
flicts cannot be avoided. Project managers mentioned
that they achieved effective partnership by working with
multi-disciplinary teams, assessing the eHealth solution
at stake from different perspectives. Some stressed the
importance of in-house IT competence as opposed to
complete reliance on external IT expertise.
While teamwork and user involvement appear to be cru-
cial factors, leadership is also an essential part of success.
The project team needs support and full commitment
from highest level of the organisation’s hierarchy.
Many eHealth solutions are developed and deployed suc-
cessfully by following an iterative approach extending
both functionality and number of users step-by-step.
This approach does of course not mean to expose users
to flawed solutions. The opposite is true. The develop-
ment team may want to separate the introduction of a
new solution into meaningful steps each creating a value
in its own right like a specific contribution to reducing
16. The majority of the many hundreds of individual cases identified in various sources could no longer be
traced some years later. 9 ...
 Good eHealth practice -
adding value
to health services

patient waiting times and/or creating added value com- Outlook

pared to the existing solution, e.g. through cost savings. Good practice cases as documented by the Good eHealth
The long-term development vision should be clear but study and evaluations of eHealth systems can be an
the team needs to define goals within a shorter time peri- important resource for decision makers, who require reli-
od and be flexible in adapting to changing user needs and able and adaptable evidence of the benefits, which would
new technologies coming to market. Often pragmatic accrue from the investments they must decide on. In a
solutions were preferred to overly sophisticated or inno- wider context, our work will be followed up and extended
vative solutions requiring a very long time horizon or a by the ‘ePractice.eu’ project in the years to come.
complete organisational overhaul. Quick wins help the The authors hope that the cases presented in this
developers to convince users of the solution’s value. brochure and those in the online knowledge base will
Regarding process reorganisation, various Good eHealth strongly support the Union-wide exchange of good prac-
cases identify two opposite approaches. Some organisa- tice and knowledge about eHealth, and foster the acceler-
tions prefer a complete process reorganisation, others to ated usage of eHealth applications for the benefit of
successively integrate the new solution into existing European and global citizens.
health services workflows. Both approaches can be suc-
cessful but have their difficulties. Complete process reor-
ganisation appears to have advantages with regard to the
ultimate benefits of the solution, but it is more difficult to
manage. In contrast, incremental solutions may fail to
reach sufficient added value needed for acceptance, but
are easier to realise.
There are also success factors directly related to technolo-
gy. Simplicity of use was mentioned several times. The
technology needs to be reliable and interoperable with
other systems. This requires that they apply common
eHealth standards wherever available. Furthermore,
when the eHealth solution is being deployed, users need
at least basic training and competent support, e.g. from
trained colleagues, but quite often also rather extended
learning sessions disconnected from their normal place
of work. Insufficient opportunities for learning and train-
ing are a key factor for failures of the whole solution.
Usually, several of such generic success factors surface in
any of the case studies. In addition, there are often also
idiosyncratic factors strongly related to the individual
application. In the individual case summaries to follow
after this introduction, lessons learned – which often
imply success factors – are described in a specific box in
order to facilitate easy access to key information.

... 10
Good eHealth practice
in European Countries

12 ...
... 12
Austria
RPS2 –
resource planning system
RPS2 is a multidimensional resource planning system
which has been employed since 2003 at the University
Clinic of Innsbruck in the accident surgery and sports
traumatology department. It integrates several auto-
nomous systems and resources and is essential for
achieving optimised clinical treatment.

The Resource Planning System RPS2 is a useful planning

tool for health service providers. While physicians pre-
viously had to make appointments with patients in a
rather time-consuming and laborious way, scheduling
procedures have been enormously enhanced through the
employment of RPS2.

Currently used in accident surgery and orthopaedics in

the University Clinic of Innsbruck, scheduling is facilita-
ted for physicians’ surgeries, daily work rotas and on and
off days. On adding a new appointment to the agenda the
system considers the respective physician’s work time, his
or her vacations, the availability of an operating theatre,
the work hours of other healthcare staff involved, the
resources needed and the legal requirements (for exam-
ple related to work time), before the appointment is
confirmed. It even considers seasonal fluctuations and an
emergency float. As a result, physicians can effortlessly
and efficiently arrange an appointment with their
patients during their consultations.
Both the project and the system were funded by the fede-
ral and state governments. In 2002 planning procedures
were initiated involving members from the University
Clinic, an organisation responsible for IT at the
Innsbruck hospitals, and a software company. Following
a planning and testing phase of six to eight months, rou-
tine operation started in 2003.
Benefits
X Planning is more efficient and reliable because RPS2
scheduling takes into consideration various aspects such
as shift and vacation schedules, as well as the availability
of resources, and because it provides a comprehensive
overview of all appointments.
X With RPS2, the hospital bed occupancy rate of the
department of accident surgery and sports traumatology
of the University Clinic of Innsbruck increased
by 10 percentage points to 85%.
X RPS2 has increased patient and healthcare staff satisfaction
because appointments have become more reliable.
Lessons learned
X Continuous discussions between the different stakeholders
involved during project planning and implementation
helped to identify and eliminate potential risk factors.
X Usability problems increased in line with the number
of features integrated in the user interface.

13 ...
 Belgium
PENTALFA – continuing
medical education through
videoconferencing
The PENTALFA project promotes state-of-the-art
knowledge about biomedical topics by offering an
internet-based and multi-disciplinary learning pro-
gramme.
Continuing medical education (CME) for professionals
is important for high-quality healthcare provision, but
can be very time-consuming. The inconvenience invol-
ved meant a reduced number of participants in CME ses-
sions at the University of Leuven’s Medical School, and a
resultant diminished spread of up-to-date information
on healthcare. The strong position of the School in CME
was further threatened by the isolated location of Leuven
in the Flemish region and by increasing traffic. To coun-
teract these difficulties, it developed PENTALFA, a video
conferencing programme, providing CME in coopera-
tion with other hospitals from the Flemish Hospital
Network.
The Medical School organises between 23 and 28 video-
conferences per year, each of them dealing with a specific
medical topic. The conferences are attended by different
experts and audiences. During the 10-year programme,
the average number of participants was 177 per session.
The videoconferencing is bidirectional - audiences can
actively communicate with the speaker’s site - and is
encouraged by including “classroom” discussions in the
programme.
Planning for the PENTALFA project started in 1997 and
routine operation commenced in 1998. The solution is
customised and structured into three layers: a steering
committee which decides on scientific content, an admi-
nistrative staff responsible for facility management and
support for the participants and finally a technical staff
... 14 operating the conference equipment on each site.
Start-up funding was mainly provided by the university,
with sponsorship from private companies. Members of
the hospital network provided funding for the upgrading
of equipment. Personnel and IT costs are paid by all par-
ticipating sites. Sponsorship is sought for the printing
and distribution of advertisement in the form of posters
and programme brochures.
According to a survey, 84.6% of participants at peripheral
sites said that they would not make the effort to come to
Leuven for this particular session if no videoconference
was available. Participants at the video sites reported a
saving of, on average, 123 minutes compared to taking
part onsite. The multispecialty approach of the program-
me leads to an audience of which only 30% share the
speaker’s specialty.
Benefits
X On average participants save 123 minutes of travel time per
video conference, resulting in three times more participants.
X The total return per participant in a peripheral location and
per hour amounted to approximately 106 euro during the
year 2005-2006.
X 65% of participants in videoconference CME report that
learning effectiveness is increased compared to classic CME.
Lessons learned
X Establish a framework to ensure that each participating
site meets the scientific, administrative and technical
requirements.
X Ensure that speakers are trained in using technical devices
and are familiar with unique “classroom” requirements.
X Keep in mind that those who benefit and those who bear
the costs of the project might not be the same people.
Belgium
Integrating hospital
information systems at
Ambroise Paré Hospital
The Ambroise Paré hospital in the city of Mons, a public
university hospital with 500 beds, effectively integrated
its dispersed information systems using a fairly simple
solution from a local IT service provider. The solution
improved workflows and the accessibility of patient
records. Any investments necessary were small, and
existing efficient specialised information systems remai-
ned untouched.

FLOW –
national healthcare network
FLOW is a national Belgian health network for healthcare
professionals working with shared healthcare patient
records. FLOW enables all healthcare providers to treat any
patient anywhere and at any time.Patients will be exempted
from multiple unnecessary medical examinations since
previous results will be available in the FLOW system.
FLOW stands for: Facilities (services and related infras-
tructure); Legal implementation (telex files); Organisations
(loco-regional teams); and Wisdom (coordination and
supervision centre). The FLOW project is financed by the
Belgian Federal Ministry for Public Health.

Flemish vaccination
database and Vaccinet
The Flemish vaccination database and Vaccinet provide
an electronically accessible vaccination record for each
child. It has been in routine operation since 2000. The
application offers the following additional functions: vac-
cination stock control and supply, a rapid and reliable
messaging channel about changes in vaccination policies
and practices, data for performance monitoring, and the
Flemish government’s strategy development. The databa-
se provides the means to boost vaccination rates and act
on vaccine shortages. 15 ...
 Bulgaria
Integrated hospital
information system at
the National Heart Hospital
The National Heart Hospital (NHH) in Sofia is the only
Bulgarian cardiology hospital that has implemented and
integrated a comprehensive hospital information
system (HIS), including medical and administrative ICT
applications.The main impacts of HIS integration were
the improved quality of patient care and improved
inventory management and logistics.
The NHH is the biggest hospital specialising in cardiolo-
gy and paediatric cardiac surgery in Bulgaria. It is a
leader in ICT use in Bulgarian hospitals. Active develop-
ment of the hospital information infrastructure and sys-
tems began in 2003. Today, ICT applications in the NHH
support the following processes: patient admission, regis-
tration, primary care, hospitalisation and discharge, clin-
ical pathways allocation, purchase and distribution of
drugs and consumables, costs calculation, accounting
and reporting, procurement management, personnel
management, laboratories investigation, as well as gener-
al management and administration. The infrastructure
consists of 250 personal computers and ten servers con-
nected to an intranet. Interoperability of the different
applications is achieved through a special interface appli-
cation - the common standard for medical data exchange
developed by a Bulgarian company that is based on XML
and which supports various software platforms.
The HIS has significantly improved the quality of health
service and job satisfaction in the NHH. Since the HIS
provides easy, rapid, 24-hour access to patient records,
physicians receive all the necessary information in sec-
onds, allowing them to treat the patient without delay.
Daily information about any medical service provided to
the patient enables management to detect mistakes and
to respond immediately. Patients know that all medical
services provided to them are entered in their records
... 16 and supervised, which increases their trust and comfort.
The costs for the patient stay in the hospital are reduced
by 10 – 15% due to the faster provision of medical servic-
es and the control over the delivery of medicines and
consumables.
Benefits
X Due to rapid access to the patient record with full medical
information, many unnecessary tests and procedures
are avoided.
X More patients can be treated in a given period of time. Costs
for patient stays in the hospital were reduced by 10 – 15%.
X The HIS improved the quality of health service significantly.
Physicians receive all the necessary information in seconds,
allowing them to treat the patient without delay.
Lessons learned
X Include the hospital’s management and staff in the
development and implementation process in order to adapt
the hospital information system to the medical requirements
and to increase motivation and work satisfaction.
X User friendliness of the solution helps
to overcome initial obstacles.
X Ensuring that healthcare staff are familiarised with
the system before they start working with it is essential
to avoid time-consuming changes.
Hippocrates – software sup-
porting general practitioners
and medical centres
The Bulgarian software “Hippocrates” creates a full elec-
tronic patient record by compiling information such as
family anamnesis, medical history and examination
results. General practitioners and medical centres can
produce all records required by the National Health
Insurance Fund according to the standards and local
codes for examinations, diagnosis, and drug prescrip-
tion. In routine operation since 2003, the system’s med-
ical and administrative functions have reduced
paperwork by 70%. It is currently used by 50% of all GPs
and 15% of Medical Centre specialists.
Cyprus
DITIS – network for virtual
homecare teams
The DITIS network enables effective collaboration and
management of virtual home healthcare teams in
Cyprus. It is a web-based system that provides electro-
nic health records (EHRs) and other supporting tools
such as messaging and ePrescription with secure
access from anywhere.

DITIS facilitates management and cooperation between

homecare health professionals from different organisa-
tions. It includes nurses, physicians, physiotherapists,
psychologists, social workers and other health professio-
nals who care for a single patient at home but neither
normally nor easily meet. They can instantly access elec-
tronic health records (EHR) via desktop computers and
mobile IT devices. DITIS provides various tools such as
instant messaging to team members, as well as automatic
notification and alerting triggered by predefined rules. It
also offers tools for improved efficiency and for minimi-
sing errors: a calendar, symptom and pain diary, medica-
tion chart, wound care assessment and information on
drug interactions. Additionally, it has ePrescription and
eReport features.
Planning of the application started in 1999 and it went to
routine operation in 2003. Currently, it is supporting the
activities of the Cyprus Association of Cancer Patients
and Friends (PASYKAF), offering homecare services to
over 600 Cyprian cancer patients every year. DITIS was
originally developed by the University of Cyprus and
PASYKAF with support from various organisations.
Development was continued in the eTen market valida-
tion projects HealthService24 and LinkCare.
Benefits
X Increased efficiency of team communication.
X Chronically ill patients and their families experience an
improved quality of life because if one health professional is
present on site, all others can be virtually present as well.
X Cost savings of up to 40% - for example staff visits to head
office for paperwork and management, as well as some visits
to patients, can be avoided.
X Audit processes, research and policy-making are supported,
as DITIS makes comprehensive data and statistics available.
Lessons learned
X Continuous use and evaluation of the application are
necessary to meet the users’ needs and to steadily improve
the application’s performance.
X Full-time support should be provided to ensure smooth
operation.
X Sufficient pre-implementation and ongoing training
for users should be provided to allow for exploitation
of the system’s potential.

17 ...
 Czech Republic
IZIP – a web-based,
nationwide electronic
health record system
The web-based IZIP is a nationwide electronic health
record system (EHR), used by all relevant stakeholders
in healthcare, including the patients themselves.
The primary objectives of the EHR system are to impro-
ve the quality of healthcare through an accurate and
rapid exchange of information among healthcare profes-
sionals and in the doctor-patient relationship; to increase
transparency and limit examinations and drugs to those
really necessary; and to involve patients in order to
extend their medical awareness.
The electronic health record includes all relevant infor-
mation about a citizen’s contacts with healthcare services
compiled for example from regular GP visits, dental
treatments, laboratory and imaging tests, hospitalisation
reports and vaccination history. Doctors can have access
to a patient’s EHR at point of care, so that each doctor can
resume treatment where the previous doctor had stop-
ped. Since 2008, patients can also see how much their
health insurance fund paid for their personal treatment.
Citizens have the right to access and consult their own
EHR, but only healthcare professionals can make changes
to the record. Citizens are able to authorize healthcare
professionals to view their data, making them a truly acti-
ve element of the healthcare system. Data security is cur-
rently guaranteed by a password and PIN system for all
healthcare professionals.
Planning for the system started in 1999 and in routine ope-
ration began in 2005. IZIP is co-funded by the largest
health insurer in the Czech Republic, covering about two
thirds of the Czech population. 10% of the population and
over one third of all healthcare organisations are currently
connected. This fully functional, nationwide system is a
globally unique flagship application which received a
World Summit Award in 2005 and was recently selected as
one of the outstanding eGovernment applications world-
... 18 wide by the European Institute of Public Administration.
Benefits
X Involving citizens in their healthcare will likely lead
to healthier citizens, better informed about their
health condition and personal health risks.
X Insurance companies benefit from the network through cost
savings, stemming from the avoidance of repeated tests and
examinations.
Lessons learned
X The system’s constant alignment with long-term goals
is essential.
X Initial problems of convincing physicians and hospitals
to participate can be overcome by offering financial
incentives, software support and training sessions.
X Health insurance may be a strong long-term partner
for funding the system.
MeDiMed –
metropolitan digital
imaging system in medicine
MeDiMed aims to create a central database of digital
images from different medical imaging devices (X-ray,
PC tomography, ultrasound, etc.) by connecting 6 health
institutions, 17 medical devices and one communication
centre in the Czech Republic. The central database sup-
ports knowledge-sharing among researcher, educational
projects (pre- and postgraduate education for medicines
and radiologists) and primary diagnostics. It currently
contains over 150,000 images.
Pecujici.online
Pecujici.online is a Czech website intended to help people
take care of their older relatives and disabled spouses.
Given the fact that nearly one quarter of the Czech popu-
lation looks after an elderly relative this application is
intended to provide home carers with useful informa-
tion, advice and support. There is even a psychiatrist
available online to answer questions.
Denmark
Remote treatment
of alcohol abusers
This Danish eHealth application facilitates access to
therapy for alcohol abusers in remote areas. Using
video equipment set up at a rehabilitation centre on
the island of Funen and two hospitals located on
remote islands, abusers are treated via teletherapy.

The application is based in the Alcohol Rehabilitation

Centre (ABC) in Funen County on the main island of
Funen. Given a remarkably low proportion of people
from the remote islands of Funen County seeking treat-
ment for alcohol abuse, the application aims at making
alcohol abuse therapy accessible: firstly, by providing
patients living in remote places with easier access to alco-
hol abuse treatment and secondly, by preventing them
from being stigmatised when entering an alcohol rehabi-
litation centre. The ABC offers teletherapy as a therapeu-
tic option for patients from the remote islands of
Langeland and Aeroe. Therapy offered at ABC is conduc-
ted as individual outpatient sessions on a weekly basis
involving only the patient and the therapist. The initial
session clarifies the patient’s situation and he or she is
subsequently offered the most appropriate type of thera-
py. The only difference from regular face-to-face therapy
is that, having made an appointment with an ABC thera-
pist, the patient only has to travel to the local hospital
where a healthcare professional assists him or her in
using a portable and fully integrated standard video
conferencing system. The connection between the hospi-
tal units on Langeland, Aeroe and the ABC is established
within the closed network of Funen County, which is
connected to the Danish Health Data Network via a secu-
red virtual private network connection.
ting costs of the application are very limited they have
been borne by Funen County without recourse to exter-
nal funding.
Evaluation results show that both patients and therapists
are satisfied with the teletherapy solution: they experien-
ce almost no difference from the traditional face-to-face
sessions. Since October 2005, 30 alcohol dependents
from Langeland and Aeroe have received teletherapy,
which represents a significant surge in the number of
patients treated.An important advantage of the telethera-
py solution is that these patients stayed longer in therapy
than the patients who received traditional face-to-face
therapy (223 days in comparison to 162 days on average).
In addition, more patients completed their treatment,
and as this completion is of great importance for the abu-
sers’ social integration, it is hoped that the new system
will have a far-reaching therapeutic value.

The planning phase started in 2003 and the system was
launched in 2004. After initial technical problems had
been solved, routine operation started in 2006. Project
officers, hospital managers, therapists and IT technicians
were involved in setting up the service. Since the opera-
An initial challenge of the project was therapists’ doubts
that patient contact would be as close as in face-to-face
sessions. This concern soon turned out to be unjustified.
Some minor problems arose with regard to the technical
equipment that, in the beginning, was not fully adapted 19 ...
 Denmark
to the therapeutic context, but those difficulties were
quickly remedied. There remains the challenge of infor-
ming all potential patients of the application. As of today,
all patients starting an alcohol abuse therapy are encou-
raged to participate in teletherapy. In a current pilot,
alcohol addicts are introduced to teletherapy during their
hospitalisation.
Benefits
X The number of alcohol abusers receiving therapy and the
duration of therapy attended has increased significantly.
X Access to alcohol abuse therapy is facilitated for patients in
remote locations.
Lessons learned
X Technical equipment has to be adapted to the healthcare
requirements: high quality has to be combined with ease of
use.
X Information about the availability of teletherapy should be
given attention in order to make it well-known and encoura-
ge patients to partake.
... 20
sundhed.dk –
Denmark’s eHealth portal
Launched in December 2003, the Danish health portal
www.sundhed.dk provides information about healthcare
providers and health promotion to citizens. For example
through the portal they can consult their General
Practitioners via e-mail, enter their GPs’ online booking
system, and renew prescriptions online. GPs themselves
can order laboratory tests through the portal.
MedCom and the Danish
health data network
The role of the Danish organisation MedCom is to sup-
port eHealth projects, to develop and implement a
nationwide health data network (DHDN), and to secure
electronic communication of local and regional projects
in the healthcare sector. Planning the DHDN started in
1994; in 2001 it went to routine operation. Healthcare
providers benefit from effective data exchange, improved
data quality and costs savings in preparing and sending
information to other healthcare services.
Estonia
PACS – nationwide instant
access to radiological images
A nationwide picture archiving and communication
system (PACS) has been established for simultaneous
archiving and viewing of radiology images produced
in different healthcare institutions throughout Estonia.
It consists of two PACS systems installed in two major
hospitals in Estonia, both containing the same data.
This central PACS receives all images taken at local
hospital PACS systems, archives them and provides the
local systems with access to these images as needed.

The system enables radiological images to be stored and

viewed electronically, so that physicians and other health
professionals can access the information and report on
the images. Images are ready for reporting immediately
after the examination. Patients may receive their images
on CD upon request.
This data exchange is performed via internet and secure
connection protocol. Currently, 42 healthcare organisa-
tions and about 800 general practitioners are connected
to the nationwide PACS, which means that 82% of all
medical images made in Estonia are sent to and retrieved
from the central PACS system. It is used not only for direct
patient care but also for education and research purposes.
Planning of the system started in 1999 and routine ope-
ration was initiated in 2006. The strategy was developed
by the Estonian Society of Radiology and implemented
under the coordination of the radiology department of
Tartu University Clinic as well as other major hospitals in
Estonia. The Estonian PACS is operated by a non-profit
foundation.
Benefits
X Reduced waiting times for patients due to rapid access
to specialists and the possibility of a second opinion.
X X-ray film expenditure is estimated to be decreased
by 90-95%.
Lessons learned
X The involvement of all stakeholders in planning and
deployment – i.e. radiologists, IT personnel, the board of main
hospitals, Medical University, Estonian Society of Radiology,
Ministry of Social Affairs – has been a precondition for success.
X A high percentage of digital image use and a good virtual
private network connection between hospitals have
significantly contributed to successful implementation.
An internet-based digital
health record system in
Estonia
The digital health record (DHR) system enables the
exchange of health data between healthcare professionals
throughout Estonia. The system aims to create a country-
wide network of centrally stored health data. The central
database includes an emergency dataset that contains
information on the contact, insurance coverage and aller-
gies; a directory that links to other sources with medical
data about the patient; and centrally stored medical
records. 21 ...
 Finland
Impacts of ICT
in the Hospital District
of Helsinki and Uusimaa
In the Hospital District of Helsinki and Uusimaa (HUS)
in Finland, electronic health services and electronic
patient records are incrementally impacting on the
role of hospitals. The most important changes regard
the relationship to patients.

The HUS comprises 23 hospitals with more than 3,500

beds in 32 member municipalities of Uusimaa province.
The HUS seeks more effective health service operations
and high-level treatment results as well as patient and
personnel satisfaction. However, the HUS vision does not
include the implementation of ICT as a goal in itself. In
the HUS, the use of ICT is already very common. The
HUS hospitals are connected to each other and to muni-
cipal health services through a regional health informa-
tion network. All HUS hospitals are filmless and have
used one central PACS for storing images since 2004.
In the HUS, patients are being given more information
about their medical conditions than previously, and as
many tests and treatments as possible are being done out-
side the hospitals. ICT supports the related flow of infor-
mation, enabling a reduction in the number of hospital
visits necessary, a reduction in the length of stay in hospi-
tal, and an increase in outpatient visits over inpatient
stays. ICT also lowers the boundaries between hospitals
and primary care centres, as information flow is speeded
up and increased. There is also increased specialisation of
hospitals in the region facilitated by ICT due to the rela-
ted enhanced level of information.
The HUS has an ICT vision for 2012. Some of the most
important elements of this vision are that: patients are
meant to contact healthcare providers from home-using
electronic communication; care personnel is meant to
have all necessary information readily available; manage-
ment is independent from organisation boundaries; and
municipalities have real-time information about costs
and quality of health services.
Benefits
X ICT speeds up and increases the information flow
between patient, primary care facilities and hospitals.
X Patients have much better access to information
about their medical conditions than previously.
Lessons learned
X While it would be technically possible to fulfil the HUS ICT
vision quite quickly, completion is not planned until 2012
because organisational changes require considerable time
for implementation.
X One of the biggest barriers to enhanced ICT communication
between primary and secondary care facilities is that
(for good reasons) doctors often do not want to rely
on impersonal electronic information.

... 22
France
Institut Curie, Paris:
Elios, a comprehensive
electronic patient record,
and Prométhée, a meta search
engine
The combination of a sophisticated electronic patient
record system (Elios) and the search tool Prométhée
allows the use of the latest research in current treat-
ment, analysing data and creating new knowledge.

The Institut Curie, Paris, France, has been a leading inter-

national research and treatment cancer hospital for a
long time. The introduction of Elios and Prométhée in
2002 was the key driver behind the active progress of
Curie towards becoming a paperless hospital. Elios is a
comprehensive electronic patient record (EPR) system. It
enables access to patients’ information by all members of
the relevant healthcare team. These include Curie’s exter-
nal partners, such as other hospitals or general practitio-
ners. Prométhée not only acts as a portal to gain easy
access to Elios, it is also a user-friendly meta-engine tool.
It enables healthcare professionals to ask specific medical
questions across a large number of Curie’s administrati-
ve, patient and clinical research databases. The advantage
of Prométhée lies in its rapid data compilation and ana-
lysis, particularly for research purposes and evaluation of
medical practice.
The implementation of both tools fundamentally trans-
formed Curie’s healthcare processes. It improved the
Institute’s medical, research, and administrative perfor-
mance. Hence, 92% of the annual benefits of these two
applications – estimated at 4-5 million euro – is reaped
by the Institute itself, and 8% by the citizens. It took Curie
7 years to achieve a positive annual net benefit, and 8
years to recover from losses that were made in the invest-
ment phase. Productivity – measured in eHealth cost per
patient – is growing steadily.
The results of Curie’s systems are particularly positive:
improvement in quality of care due to better informed
professionals, time-savings for doctors and administra-
tion, improved collaboration between doctors in relation
to specific patients, and cost-savings on both paper and
archiving. The commitment of the Curie’s stakeholders
(board of directors, multidisciplinary teams and clini-
cians) to this pragmatic step-by-step approach is reco-
gnised as one of the two systems’ major success factors.
Benefits
X Improvement in quality of care as a consequence
of extensive knowledge-sharing among practitioners.
X For 2008 annual benefits are estimated to exceed the annual
costs by 4,3 million euro, with the institute reaping 92%
of the annual benefits.
X Significant time-savings for doctors and administration and
cost savings on paper and archiving due to the EHR system.
Lessons learned
X Continuous commitment of management and clinicians
was essential for the positive outcome.
X A great effort was however needed to keep this commitment
over a development period of 7 years. 23 ...
 France
Arras public hospital
information system
In 2000 a public hospital in Arras, in Northern France,
had run up heavy financial losses and was dependent on
a patchwork of hardly integrated information systems. As
a solution to tackle both problems an entirely new hospi-
tal information system (HIS) was envisaged. It comprises
a hospital record management system and both perfor-
mance management and enterprise reporting software.
The investments in IT infrastructure lead to improve-
ments in clinical workflows and made them profitable
again. Investment amounted to 3.5% of the hospital
annual budget, being 2% over the national average.
DPPR – a patient record
for the Rhône Alpes region
The Shared and Distributed Patient Record (DPPR) used
in the Rhône Alpes region enables clinical information
about a patient to be shared among those physicians who
deliver care to the same patient. Physicians have real time
access to patient data which is stored remotely at a variety
of locations. The DPPR essentially relies on the identity
server STIC, which helps to match the different identifiers
used in the different systems. Since its start in 2005, use
has grown continuously, currently housing over 100,000
health records and linking 30 different data sources.
... 24
RIPAM – Southern Ardèche
patient information network
The Southern Ardèche Patient Information System
RIPAM remotely stores patients' health records which are
accessible by both patients and healthcare professionals.
Since 2004 the application has been used by physicians in
various public and private hospitals, private practices
and diverse laboratories and imaging centres in the
French Ardèche region. The personal health record
contains information on patients’ allergies, vaccination,
their social and general context, organ donorship, health
insurance specifics, current treatment, etc. and access to
this information is exclusively authorised by the patients.
COHERENCE – a clinical
information system of
Georges Pompidou Hospital,
Paris
COHERENCE is a comprehensive clinical information
system (CIS) implemented in the Hôpital Européen
Georges Pompidou (HEGP). Opened in 2002 HEGP
completely redesigned the care workflow and around
that built a new hospital building and tailored off-the-
shelf ICT components to fit that redefinition of hospital
care. One of the biggest hospital reorganisations in
Europe resulted, for example, in increased nursing per-
sonnel bedside presence (from 1.43h to 1.52h/bed), or a
reduction of the average length of stay by one day.
Germany
Medical Online Portal
of the Ingolstadt Hospital
The Medical Online Portal of the Ingolstadt Hospital
(Klinikum Ingolstadt) in Germany optimises input and
retrieval of information at the point of care.The use of
tablet PCs for filling in forms, accessing laboratory
results and scheduling examinations allows for increased
value in healthcare services such as diagnosis, therapy
and rehabilitation.

The Medical Online Portal is a communication platform

that connects all healthcare professionals in the hospital.
The Ingolstadt Hospital serves 35,000 inpatients and
40,000 outpatients. Before the portal was implemented,
patient-related information was collected on paper forms
and then inserted manually into the electronic informa-
tion systems spread throughout the hospital for further
processing. This time-consuming handling of data meant
the 3,000-strong healthcare staff had less time to spend
on healthcare activities. It also hampered communication
for hospital staff and imposed longer waiting times on
patients.
The current solution interconnects the hospital’s data-
bases, e.g. for radiology, patient records or patient admin-
istration, via web services. The physician on duty enters
data into the different forms using a tablet PC. This infor-
mation can be retrieved at any time, thus avoiding dupli-
cation of patient data gathering. The physician can also
schedule x-rays, laboratory tests or ultrasound examina-
tions at the same time, without re-entering patient infor-
mation. In order to protect sensitive patient data, the
digital forms are signed manually, like paper forms.
Authorisation and identification are ensured by the auto-
matic registration of biometric attributes such as the
direction and speed of writing.
Various benefits arise from the optimised and more
rapid data exchange and entry:
kSimplified filling-in of forms and avoidance of duplica-
ted data gathering results in a time reduction of about
five minutes per patient at admission, resulting in
2,000 hours saved in the emergency room every year.
kImproved search for medical information adds up to
35,000 Euro per year. Faster and more reliable deci-
sion-making are not included in these figures.
kIn general the risk of entering and receiving wrong
information is reduced, due to basic elements of a
computerized physician order entry system (CPOE).
Initially, an online system had been implemented in the
emergency room in 2004. The eHealth Integration
Platform, connecting various hospital systems, was estab-
lished in 2005. In 2007 the Medical Online System started
its routine operation. The application is predominantly
funded by the hospital itself, anticipating efficiency gains
to compensate expenditures. Based on the hospital’s
experience it can be concluded that positive outcomes
require user feedback, acceptance and support.
Additional costs caused by data storage in paper format
due to legal requirements were underestimated and have
to be borne in mind. 25 ...
 Germany
Benefits
X Work time savings of 2,000 hours annually due to improved
administration procedures, resulting in additional time
for healthcare activities.
X Cost savings of approximately 35,000 Euro per year,
due to enhanced search for medical information.
X Identification of users by biometric characteristics
increases patient data protection.
Lessons learned
X Bear in mind that paper records may have to be stored
for legal requirements and may demand additional costs.
X Update the system, taking into consideration users’ feedback.
X Introduce the system incrementally in order to increase user
acceptance.
Jeder-fehler-zaehlt.de –
platform for information
on medical errors in general
practice
The website www.jeder-fehler-zaehlt.de (“every-error-
counts”) is a service tool for primary care physicians and
practice assistants who recognise that knowledge of
medical errors can be used to improve patient safety.
Providing an opportunity for healthcare professionals in
general practice to report incidents, the website is aimed
at collecting and analysing reports in order to generate a
general understanding of the errors.
RFID wristbands and
computerised prescribing
at Saarbrücken Hospital
In order to avoid adverse drug administration, patients at
Saarbrücken Hospital (Klinikum Saarbrücken) are
equipped with RFID (radio frequency identification)
wristbands to have information on their medication avai-
lable any time. Since these wristbands are linked to their
... 26 centrally stored data, previously prescribed medication
can be retrieved by holding a pocket or tablet computer
equipped with an RFID reading unit near the patient's
wrist. Additionally, health professionals are recommen-
ded or warned against certain prescriptions and receive
an alert if a dose is missed or was already administered.
MedicalOrder® Center
Ahlen – supply chain
optimisation
Several hospitals in the Münster region gave up their
local warehouse, pharmacy, purchasing department and
sterilisation unit and centralised it in a single building -
the MedicalOrder® Center Ahlen (MOC). By means of an
ICT-supported storage and supply system the hospitals
automatically order medical and pharmaceutical pro-
ducts from the MOC which can, if needed, deliver in 30
minutes. The MOC helps to reduce stock levels in the
hospitals and can reduce product prices due to joint
ordering.
GesundheitsCard Europa
(GCE) – access to healthcare
abroad
Since 2003 patients insured by AOK Rheinland in
Northwest Germany can be treated in 14 hospitals across
the border to the Netherlands and Belgium by presenting
their GesundheitsCard Europa (GCE). This card is also
their German health insurance card. In this way, patients
can receive treatment abroad as conveniently as in their
own country. A web application enables the hospitals to
verify insurance coverage and to initiate reimbursement
procedures.
Greece
Integrated pre-hospital
health emergency services
in the Crete region
An integrated pre-hospital health emergency mana-
gement system was developed to support optimal
response management of pre-hospital health emer-
gencies.

The pre-hospital emergency management system (EMS)

is an integrated information and communication system
that enables optimal response management by pre-hospi-
tal emergencies on a regional level. Given that the first 60
minutes are the most critical ones regarding long-term
effects on patients, the employment of various modules
of the EMS helps to provide vital healthcare in time.

Through intelligent triage algorithms the operator-
dispatcher application is able to generate an ‘incident
card’, evaluating the type and severity of an incident and
selecting the most appropriate mobile (intensive care)
unit for the incident.
With the remote monitoring and management module,
first observations and ECGs by the mobile unit can be
directly transmitted to a physician at the dispatching cen-
tre who in turn can give advice to the paramedics.
Information that has been generated or transmitted is
recorded on the onboard computer of the mobile unit.
Information in the complete archive of emergency episo-
des is used for administrative decision-making, e.g. for
hiring, training, statistics and the acquisition of specific
equipment.
minutes and transfer time from 18 to 14 minutes.
Furthermore, the initial decision by the dispatching unit
regarding the assignment of the most appropriate resour-
ces turned out to be correct in 82% of the approximately
40,000 cases per year. This is considered a substantial
improvement on the situation before the implementation
of the EMS.
Funding initially took place in the framework of EU pro-
jects such as HECTOR and JUST, and the implementa-
tion of a regional health information network (RHIN) of
Crete. Later, the implementation of the required eHealth
technology in all mobile intensive care units of the region
was financed by the Regional Healthcare Authority.
Maintenance and support costs are borne by the National
Centre for Emergency Care.

The planning phase was initiated in 1996 and after gra-

dually extending the system, routine operations began in
2000. The results were very positive: response time drop-
ped significantly between 2000 and 2006. Dispatch time
dropped from five minutes to one, arrival time from twel-
ve to five minutes, time at the scene from twelve to five 27 ...
 Greece
Benefits
X A significant reduction in time for response management.
X A substantial improvement in the accuracy of decisions taken
by the dispatcher regarding the assignment of resources.
X Expected ‘spill over’ effects on the main economy of Crete,
for example tourism, through an increase in confidence
about the quality of healthcare services on the island.
Lessons learned
X Ensure that both the technical equipment and
the implementation team are capable of achieving
the changes required in such a complex setting.
X Secure uninterrupted financial support from the concept
phase to the point of routine operation.
X Look for an ‘internal champion’ with the ability
to continuously mobilize and motivate people
for the project.
... 28
CardioExpress
telemedical services
CardioExpress telemedicine services is a company which
operates a modern call and control centre with the aim of
providing instant evaluation on a case-by-case basis and
suggesting the best available treatment options. An expe-
rienced team of eight cardiologists responds to patients’
calls and analyse the available clinical information and
symptoms provided by the patient or by his EHR. In the
case of a cardiological problem that could be treated
through self-management, an appropriate care plan is
defined including the required medication.
Delivering home care
for chronically ill patients
by Sotiria Hospital in Athens
Sotiria Hospital implemented an e-health application for
long distance monitoring of patients with a specific type
of chronic disease. After an initial phase of training the
patient on how to apply the required follow-up technolo-
gies, the e-health unit within Sotiria hospital is able to
telemonitor the status of the patient and televisit the
patient regularly via video-conferencing sessions. Behind
this home-based follow-up system is the idea of empowe-
ring the patient and increasing the degree of self-mana-
gement abilities, autonomy and feeling of safety, to the
advantage of the patient.
Hungary
TIP – the transplant
information portal
The Hungarian transplant information portal ( TIP)
facilitates the process of matching patients and donors
by connecting as many donors and receivers in an
information system across the borders of European coun-
tries as possible.
It is the aim of TIP to develop and share its portal tech-
nology with users all over Europe and to establish net-
works between European countries and regions. By
providing all stakeholders with relevant information the
entire transplantation process can be supported: a web-
based electronic health record, which is the core of the
platform, allows for retrieving medical information on
donors and receivers. In order to find a matching donor
the physician in a dialysis centre can generate a new
patient file, entering the tissue type of the patient for
whom he or she is seeking an organ. Other attending
physicians can also add further relevant information.
Patients who are on the waiting list have a smart card or
transplant card, and, if authorised by a healthcare profes-
sional, have access to their own records. In addition, the
system has several tools available to assist healthcare pro-
fessionals in the process of tissue typing and organ
matching. Medical information can be translated to and
from other languages and the relevant information is
organised in folders representing the clinical pathway of
organ transplantation. Besides giving support in finding
matching organ donors, TIP also creates a transparent
process of organ search and location.
Funding was provided by the Ministry of Informatics
and Communications stemming from a research and
development programme. Planning procedures started
in 2000 and after a system evaluation and nation-wide
roll-out the routine operation was initiated.
Benefits
X The likelihood of finding a matching donor is significantly
increased due to the large number of donors and the exchange
between both groups.
X Time on the waiting list is shorter as decisions can be based
on reliable, up-to-date information.
Lessons learned
X Only through close cooperation between transplant surgeons,
immunologists, nephrologists and other physicians can
the portal’s potential be fully realised and the efficiency
of organ transplantation increased.
X Basing the application on a pre-existing conventional clinical
information system makes successful operation more likely.
Anesztinfo OJE – a nationwide
anaesthesiological information
system
The Hungarian Society of Anaesthesia and Intensive Care
(HSAIT) developed the anaesthesiological information sys-
tem ANESZTINFO NRS (Nationwide Reporting System).
The system aims at simplifying the nationwide process of
data collection in anaesthesia and intensive care. Data from
related hospital departments has to be gathered, summarised,
analysed and sent to healthcare authorities. The application’s
routine operation started in 2003.
29 ...
 Ireland
Vhi.ie – a web-based
interactive health
information resource
for the general public
Vhi.ie is a comprehensive electronic gateway for Irish
patients to gain extensive information on health issues.
It has a library of health and lifestyle articles, an A-Z of
medical matters, an ask-the-experts interactive serv-
ice, an extensive range of interactive online health
promotional tools, and a monthly personalised e-mail
newsletter available.
Benefits
X The portal has 300,000 site visits per month and more than
112,000 registered users, of whom 60% are Vhi Healthcare
members, indicating highly beneficial contents.
X The overall reputation of Vhi Healthcare (and therefore
customer loyalty) has apparently improved: 87% of members
who visit the portal service regularly reported an improved
image of their health insurance company.
Lessons learned
X The portal’s maintenance, regular input, information
reviewing and managing is continuous and time-consuming,
and thus cost intensive.

Vhi.ie was launched by the health insurance fund Vhi

Healthcare. The portal service was implemented in com-
Irishhealth.com – an Internet-
pliance with Vhi Healthcare’s eHealth strategy to meet based health resource
consumer demands for health and lifestyle information IrishHealth.com is a comprehensive source of healthcare
and to increase contact with its insurants. It provides sup- information, offering quality assured and locally pro-
port with regard to these topics in order to promote duced health information to all Irish citizens. With the
healthy living among its members and the Irish popula- overarching goal of patient empowerment, the website
tion in general. aims to promote beneficial health outcomes, to address
the lack of provision of healthcare information at nation-
It is organised into main and sub-categories dedicated to al level and to enable citizens to interact better with the
different aspects of healthy living, for example diet and national health system.
nutrition and health at work. These categories are addi-
tionally targeted at different groups such as elders or stu-
dents. Members also have the opportunity to exchange
experiences and discuss health topics. The service is reg-
ularly reviewed with regard to usability and meeting the
demands of target groups. The Vhi health insurance fund
says that it is committed to inter-generational support
rather than a risk-rated system in its reimbursement
structure. Thus, health promotion plays an important
role in achieving lower health-related claims among
younger age groups.

Vhi.ie is entirely funded by Vhi Healthcare. The planning

phase started in 1999 and routine operation was launched
in 2000.

... 30
Italy
RESPECT – telemedicine serv-
ice for neurological emer-
gency cases

The RESPECT service is an innovative telemedicine

system which supports healthcare professionals in their
management of neurological emergencies in peripheral
areas of Italy.

RESPECT stands for “regional network for the manage-

ment of neurological emergency cases through telemedi-
cine”. The primary objective of RESPECT is to improve
the management of neurological emergency cases:
through better access to highly specialized healthcare for
citizens from less densely populated areas (the province
of Messina) and through knowledge-sharing between
specialist centre and peripheral healthcare services.

Emergencies, such as a stroke or a cranial trauma, require
prompt and effective treatment. In the case of a stroke for
example, a systemic thrombolysis intervention within the
two subsequent hours could lead to a significant improve-
ment in the patient’s situation. However, such an inter-
vention could only be carried out in specialized centres
situated 30 to 100 km from Messina or that are difficult to
reach. RESPECT overcomes this distance barrier by
using a telemedicine approach.
RESPECT is based on a web platform that allows real-
time sharing (streaming) of data and high-resolution
medical images between specialists and physicians. The
specialist centres are equipped with PC viewer stations,
while the peripheral sites in the Province of Messina are
supplied with a workstation which they use for sharing
medical images with the specialist centres. Based on the
images that have been transmitted, practitioners from the
specialist centre evaluate further actions to take for a spe-
cific emergency case and fax their recommendations
back to the peripheral site. The overall procedure takes
no longer than 15 minutes.
The project began in July 2003 and received funding
from the Italian Ministry of Innovation. It is currently
financed by local health agencies. After a positive evalua-
tion, the geographical scope of the telemedicine solution
was extended to other less densely populated areas, and
the pathological scope was broadened to stroke events.
Benefits
X Access to highly specialized healthcare for citizens
from less densely populated areas.
X Appropriate and rapid intervention with less inconvenience
to the patient. Around 90% of the operators from peripheral
sites agreed that the efficiency and quality of the assistance
delivered improved significantly.
X Cost savings due to the reduction of the number of patient
transfers to specialist centres (52% between 2003 and 2004).
X Better quality of diagnosis, due to knowledge-sharing
between healthcare professionals.
X Average time to provision of specialised treatment
has dropped from 160 to 40 minutes. 31 ...
 Italy
Lessons learned
X Involve all stakeholders in the project implementation
process in order to increase the overall acceptance
of the application.
X Allow enough time for training activities and learning
processes to take place so that resistance to the application
can be overcome.
X Conduct a project assessment to prove the system’s
positive outcomes.
Health Optimum –
healthcare delivery
optimisation through
telemedicine
Health Optimum provides telemedicine services to opti-
mise the healthcare services’ workflow and promote
access to local best practices by using teleconsultation
and telelaboratory applications in the Veneto region. A
request form with the personal data of a patient and
other relevant information is electronically signed by a
regional technical workgroup and sent to a neurosurgery
specialist, who expresses his opinion electronically. Since
initial operation in 2005 there has been a significant
reduction in the number of patients hospitalised in spe-
cialist centres, and significant cost and time savings.
... 32
Telecardiology in Italy –
benefits from a telemedicine
network
The Health Telematic Network provides a 24-hour tele-
cardiology service to the entire region of Lombardy, using
clinical data and recording biological signals. Patients’
electrocardiogram data is transferred to a call centre and
monitored by nurses who may pass on the data to a team
of cardiologists throughout the region. The network
improves cardiology services and resources allocation
though integrating rapid second opinions for GPs, home
telenursing and call centre services for hospitals.
RFID at the Istituto
Nazionale dei Tumori
Since 2005 the Istituto Nazionale dei Tumori in Italy uses
an RFID application for the traceability of blood bags in
order to improve patient safety. To ensure correct identi-
fication of patients and the allocation of blood bags,
nurses and physicians make use of handheld terminals
with RFID antennae, a wristband for the patient and a tag
installed at the hospital bed. The system recognizes dis-
crepancies between the data read from the bag and the
patient’s wristband and stops the blood transfusion.
Latvia
Latvian MIS – web-based
national health services
management information
system
The Latvian management information system (MIS)
administers all relevant information about inpatient and
outpatient services, contracts, finances, and statistics
throughout the country.It also allows for the centralised
procurement of medicine. Healthcare providers can
access patients’ medical history via this system.
The system serves the state’s health funding for primary
healthcare and emergency services in accordance with
the national reimbursement patterns. The primary objec-
tives of MIS are threefold: firstly, to implement the state
policy for the provision of healthcare services, secondly,
to administrate the State’s compulsory health insurance
resources and, thirdly, to provide operative and accurate
information exchange between the Health Compulsory
Insurance State Agency (HCISA) and the various health-
care providers. Latvia’s healthcare system is both state
and privately funded, with the state providing basic
healthcare services including primary healthcare and
emergency care. The HCISA administrates the state
funding and distributes it among healthcare institutions
including general practitioners (GPs).
The Latvian MIS is a centralised three-level web-based
system supervised by HCISA, consisting of 14 modules:
user management and basic security system; a reim-
bursement system; a register of participants of the Health
Compulsory Insurance fund; a register of medical insti-
tutions and medical professionals; a waiting list manage-
ment system (for some healthcare services); an
accounting system; a system for contract and funding
regulations for in- and outpatient and dentistry services;
emergency medical care; data analyses and statistics; a
system for centralised procurement of medication; and a
system for the management of the European Health
Insurance Card (EHIC). Recently, a public health module
monitoring the spread of infectious diseases in Latvia
was integrated.
The MIS is based on an Oracle platform software whose
interface modules have been programmed in a special
manner to allow easy exchange of information between
healthcare providers and the MIS. Advanced information
security tools are used for the safe-guarding of data
against loss, misuse or damage. GPs can access the system
directly, provided they have the necessary technical sup-
port, i.e. computers, internet connection and sufficient
ICT skills. Otherwise they will have to ask the HCISA to
enter their data into the MIS, in order to be able to invoice
their services.
Benefits
X Costs of health services can be managed efficiently
and in accordance with national reimbursement patterns.
X Important information can more easily be administered
and exchanged among different healthcare providers.
Lessons learned
X Make sure that a large-scale eHealth project has
the support of the relevant authorities.
X The fact that some GPs had no computers and were not
connected to the internet hampered cooperation between
different healthcare providers and the exchange of patient
information.
A nationwide electronic
patient record system
A sophisticated solution allows hospitals to access all rel-
evant information about every contact patients have with
the healthcare system in Latvia, for example general prac-
titioner and hospital visits, dental treatments, laboratory
and radiology tests. The objective is to reduce time devot-
ed to documentation as well as to improve and facilitate
the compilation of statistical data.
33 ...
 Lithuania
Eastern Lithuania
Cardiology Project
The Eastern Lithuania Cardiology Project is a complex
ICT-based network of cardiology assistance. It aims to
improve the delivery of healthcare services in rural areas
of Lithuania for patients with cardio- and vascular dis-
eases.The project modernises and optimises the exist-
ing infrastructure.
In Lithuania, the highest morbidity rate is related to car-
dio- and vascular diseases. The Eastern Lithuania
Cardiology Project covers a region of 15 local authorities.
The aim is to achieve optimised diagnostics and health-
care provision, improved access to, and quality of, care,
renewed technical standards and implemented informa-
tion technologies.
The network of cardiology assistance covers and inte-
grates primary, secondary and tertiary healthcare provi-
sion. It comprises 40 healthcare institutions (23 primary
care facilities, 15 hospitals and two major rehabilitation
centres for children). It is situated both in rural and
urban areas. Two major university hospital centres in
Vilnius and Kaunas are also integrated. Part of the net-
work’s functionality is medical data exchange between
health professionals, receiving second opinions from
remote healthcare colleagues and monitoring.
The project started in 2004 and led to routine operation
in 2007. 80% of the funding accrues to the EU Structural
Funds, complemented by funds from the Lithuanian gov-
ernment.
... 34
Benefits
X The capacity to provide cardio-vascular health services
to outpatients in the relevant regions has increased by 20%.
X Waiting times for hospital outpatients seeking
cardio-vascular disease consultation has been reduced
from 2-4 weeks to less than one week.
X Healthcare is provided within reach of patients’ homes.
Lessons learned
X A “waterfall approach” for implementing the system instead
of a “big bang approach” proved to be successful.
X Extensive attention needs to be paid to clinical staff
using the end product. Appropriate training and
assistance needs to be provided.
X Learning from international experience contributed greatly
to the system’s positive outcomes.
eHealth system development
in the Lithuanian healthcare
sector
The national eHealth system of Lithuania was imple-
mented in order to replace the fragmented and poorly
organised information and communication technologies
(ICT) in the healthcare sector. The new eHealth system
provides consistent, rational and coordinated activities as
well as technical solutions in order to enable electronic
exchange of medical data.
Luxembourg
Wikifood.lu – enabling
citizens to avoid food allergies
Wikifood.lu is a simple-to-use internet portal that enables
citizens with food allergies to identify which pack-
aged foods contain allergens to which they might
have a reaction. Details of some 13,000 food products
are on the Wikifood website.
For patients, managing a food allergy means avoiding
eating particular allergens. When an allergen has been
ingested accidentally or unintentionally, it means it is
important or even urgent to seek some form of therapy.
However avoiding these allergens is not always easy as
reading the list of ingredients on all the products one
buys is a cumbersome task and not all products have a
complete list of food ingredients.
Wikifood helps allergic persons when planning their
shopping or meal in listing all products that they need to
avoid. As of December 2008, Wikifood had 12,630 foods
entered on its database. When searching the database
various different types of foods can be chosen, including
special dietary preferences. Since recently also cosmetics
are included in Wikifood to help avoiding contact aller-
gies. An indicator for the success as well as the need for
this platform is that the number of food products regis-
tered has doubled within the last 18 months. Since its
start in early 2006 usage has grown steadily totalling in
90,000 visits over the past six months.
Wikifood’s operation is built on a volunteer network of
about one thousand food product users. Users complete
the database by typing in the ingredients’ lists of products
that may be interesting to allergy patients and consumers.
Digital photos of bar codes, packages, and ingredient lists
help to validate the data entries.
Not only patients or citizens are involved with Wikifood.
Various import functions can enable data to be incorpo-
rated into the application from existing databases or text
files. As a result, food producers or retailers can demon-
strate their concern about and interest in food security by
delivering information about their products to the
Wikifood community. Wikifood is supported, among
others, by Cactus Supermarkets, which is a Luxembourg-
based largely organic supermarket chain and Haus
Rabenhorst, a German food producer.
Unfortunately the application does not yet contain a
complete list of food ingredients. Ecological and bio-
food producers and retailers, and smaller companies,
have been keener and quicker to get involved. More con-
ventional producers and retailers have been less so.
Efforts are being made to enhance the relationships with
larger corporations.
Wikifood was originally national in its parameters, but it
is increasingly international, especially among German-
speaking countries. Possible take-up at a wider European
level is currently being explored and a French and English
version of the portal is already available.
Benefits
X Allergic persons can avoid buying food containing
allergens more easily.
Lessons learned
X A complete list of food ingredients is difficult
to obtain especially from conventional food producers.
35 ...
 Malta
National eHealth portal
Malta’s eHealth portal (www.ehealth.gov.mt) is a web
platform serving both information and interaction
purposes.Besides offering general information on health-
related issues, the portal facilitates communication
between citizens,patients and their healthcare providers.
A longer-term goal is to enable more advanced trans-
action-based services requiring registration and authen-
tication.

Malta’s national eHealth portal was initiated by the

Maltese Ministry of Investment, Industry and IT in 2004
and became operational in 2006. It allows residents and
tourists access to various health services on the web. For
example, Maltese citizens can apply online for a European
Health Insurance Card, enrol online with the National
Blood Transfusion Centre as a potential blood donor,
apply for weight reduction and smoking cessation clinics,
send online requests for healthcare counselling, and sub-
mit online public health complaints. The portal also
includes an online emergency pharmacy roster.
Most of the eServices hosted on the portal have been
taken up quite well, while some - e.g. online registration
as a blood donor - have not. This was at least partly due to
the difficulties that arose around the Government elec-
tronic identity (e-ID) component of the portal: For some
of the services, access depends on possession of a valid e-
ID by the person requesting the service. Notwithstanding
these initial difficulties, further integration of eServices
with the e-ID infrastructure is a dedicated objective, as it
will facilitate the provision of more advanced transac-
tion-based services.
Benefits
X Practical one-stop-shop for health services, providing
information and transaction services.
X Opportunity to pilot e-ID based applications: other projects,
most importantly the e-ID, will benefit from the experience
of the end-user acceptance gained through the portal.
X Modular ePortfolio: new eHealth services can be developed
and added over time, taking into account demand and
the experience from the provision of other services.
Lessons learned
X Difficulties with the e-ID component of the portal:
uptake was not good of some of the services requiring
e-ID registration (e.g. online registration as a blood donor),
due to difficulties with using the e-ID infrastructure.

The portfolio of eServices available through the portal is

due to be further expanded. A market analysis has been
issued to identify those areas with the highest potential.
Possible services are in the fields of progeny (reproduc-
tive care), breast care, diabetes care, speech/language
pathology and services for the elderly.
... 36
The Netherlands
The Thrombosis Digital
Logbook
The Thrombosis Digital Logbook is an electronic health
record system which enables home-monitoring for
thrombosis patients in the Netherlands and Germany.
The system allows patients to perform their blood analy-
sis at home and still have their data monitored by the
Thrombosis Services. Instead of going to the hospital for
blood tests 18 times per year, thrombosis patients have
the opportunity to log on to their Digital Logbook every
ten days in order to submit their data. The Logbook elab-
orates a new dosing scheme based on the registered blood
values and the individual patient record. Blood results
diverging from the established parameters of the system
result in intervention by the healthcare professional, who
holds ultimate medical responsibility. In addition, the
Logbook enables interaction between patient and health-
care professional through free text messages as an alter-
native to inbound phone conversations.
The Thrombosis Digital Logbook offers significant time
and cost savings in terms of supervision and paperwork.
The thrombosis services spend about five hours annually
on educating a self-managing patient to use the Digital
Logbook, whereas supervision of the same patient on a
face-to-face basis would amount to ten hours per year.
Moreover, home-monitoring not only results in more
flexibility and independence, but also creates a feeling of
empowerment which results in increased patient compli-
ance.
Planning procedures on the Digital Logbook started in
2002 and one year later the system began routine opera-
tion. Based on HL7 and Snomed CT standards the log-
book can be linked with laboratories and hospital
information systems. Currently more than 10.000
patients make use of the Digital Logbook.
The Thrombosis Digital Logbook was developed by
Portavita, a private Dutch company specializing in multi-
disciplinary chronic disease management systems. In
2005, the Thrombosis Digital Logbook won the ICT
award for Innovation 2005, organized by the Ministry of
Economic Affairs.
Besides the EHR for anticoagulation treatment, the solu-
tion is also available for diabetes, stroke and COPD treat-
ment.
Benefits
X Empowerment of the patient through self-management,
resulting in patient compliance, high satisfaction and
a feeling of independence.
X Significant time and cost savings with respect
to the supervision of patients.
X The “medical cooperation” intensifies the relationship
between health professional and patient.
Lessons learned
X Provide sufficient training capacity
for self-management patients.
X Convince health suppliers of the positive outcomes
of the new health management system
to foster patient acceptance.
Zorgdomein (“Caredomain”)
– internet referral application
This internet referral application intends to bridge the
information gap between primary and specialized health-
care services and to decrease the number of unnecessary
specialist consultations. The application automatically
transmits referral information from the GP to the hospi-
tal information system and vice versa and allows GPs to
arrange appointments with specialists for their patients
through the internet. It ensures rapid feedback from the
hospital to the GP after the referral and gives the GP
insight in the care products of the specialized services. 37 ...
 The Netherlands
Meavita – Tele-homecare
for chronically ill patients
A private company in the Netherlands, Meavita, treats
chronically ill patients via the internet through their own
TV, using a specific box, a camera and a remote control.
Driven by the permanent shortage of nursing and
increasing healthcare costs in the Netherland, the compa-
ny looks for tele-homecare alternatives for treating these
patient groups. Patients can make direct contact with a
nurse, working for the homecare delivery company.

Portal website for in-

vitro fertilisation treatment
The portal website aims to self-empower patients who
undergo in-vitro fertilisation (IVF) treatment in a rou-
tine care situation. The portal makes use of the nation-
wide public key infrastructure (PKI) for access control
management. Besides general information on infertility
and IVF treatment patients are enabled to view all digi-
tally available information concerning their IVF/ICSI
treatment in their personal health record, and to commu-
nicate with their physicians and other patients.

... 38
Norway
Blood donor booking
through SMS and internet
Since 2003 blood banks in Norway have employed a
blood donor booking system that allows electronic com-
munication between blood banks and blood donors.
Now covering 20 blood banks in Norway, this applica-
tion serves to achieve a stable and predictable blood
store without time-consuming “invitation” proce-
dures.
Blood banks need to sustain the attention of potential
blood donors to ensure that hospitals obtain sufficient
blood to save patients’ lives. However it is very time-con-
suming for blood banks to constantly urge and invite
potential blood donors through phone calls or by mail.
In order to avoid the traditional way of making blood
donation appointments, the Norwegian blood donor
booking system allows blood banks to handle the
appointment process via computer. Currently, 20 blood
banks and 25,000 donors use the system. It has a module
for communicating with donors by SMS and e-mail and
for inviting them to, and reminding them of, donation
appointments. Communication is limited to standard-
ised out-going messages and simple yes/no replies. The
communication module is connected to the internal
booking module. Upon reception of a donor’s reply the
system will immediately and automatically confirm or
withdraw the appointment.
Planning started in 1999 and the system went to routine
operation in 2003. One third of the expenses were cov-
ered by the Norwegian Directorate for Health and Social
Affairs. Governmental funding of investment costs
ceased in 2005.
Benefits
X The number of blood donors who confirmed
an appointment but did not show up decreased by 15%.
X The efficiency of donation scheduling has been improved
significantly: blood banks can make appointments
at short notice, and can reach more people
in less time without much effort.
X Blood supply has grown, and is more stable
and predictable.
Lessons learned
X The costs of running the system are insignificant
compared to its benefits.
Electronic messaging between
health service providers
Throughout Norway electronic messaging is a common
means of communication between health service
providers, including electronic health record (EHR) sys-
tems. Hospitals, private laboratories, government bodies
and general practitioners can send and receive, for exam-
ple, analytic test reports, sick leave notifications as well as
referral and discharge letters. The computerised commu-
nication of such documents has improved cost effective-
ness and continuity of care.
39 ...
 Poland
Digital imaging systems at
John Paul II Hospital in
Cracow
The implementation of a picture archiving and com-
munication system (PACS) as well as a radiology infor-
mation system (RIS) was the most important part of
the ICT strategy of John Paul II Hospital.It led to increased
quality of care and cost reductions.
John Paul II Hospital in Cracow is one of the most mod-
ern hospitals in Poland. It has approximately 520 beds
and 40 specialised laboratories as well as a diagnostics
centre for heart and lung disease. The centre conducts
about 100,000 tests and consultations yearly, including
60,000 imaging examinations.
Due to constantly decreasing public healthcare expendi-
tures, the implementation of appropriate ICT applica-
tions was meant to facilitate both administrative and
health operations. However, the core driver of ICT imple-
mentation in the hospital was improved provision of
patient care. The hospital’s ICT strategy was established
in 2002. Its aim was to become an “e-hospital”, which
would use integrated digital networks in all departments
and integrate the hospital's network with external institu-
tions. Since 2002, all operational applications and sys-
tems have been modernised and integrated. Most
important for providing healthcare was the implementa-
tion of a PACS and a RIS. Due to the high importance of
diagnostic imaging in patient care, especially in the spe-
cialist clinics, the managing directors decided to replace
the expensive, time-consuming, manual film-based sys-
tem with digital technology.
Digital imaging brought considerable cost benefits to the
hospital. An X-ray picture is costly, demands a certain
processing time and requires storage solutions. Apart
from material costs, the hospital achieved sustained sav-
ings on imaging operations. Today, only two people are
... 40 involved in conducting and delivering the tests on CD,
whereas previously at least three departments and several
people were involved. Furthermore, the storage space for
radiology film processing, administration and archives
was reduced and the space is now used for consultation
purposes, thus increasing the hospital’s capacity. The
hospital also achieved considerable efficiency improve-
ments in diagnosis due to reduced delivery time, anytime
access and better co-operation as images can be viewed
from multiple terminals and locations. Efficiency also
improved due to a reduction in the number of lost or
misplaced images, more efficient time management and
research and education support.
The greatest benefit for patients is that images are no
longer lost or misplaced, which previously led to post-
poned or cancelled appointments and repeated X-ray
exposure. Patients no longer have to bring their X-ray
images with them for appointments in the hospital.
Benefits
X The deployment of ICT systems for digital imaging
has improved quality of care and reduced cost.
X The greatest benefit for patients is that images are
always readily available.
Lessons learned
X Due to a lack of interoperability, John Paul II Hospital cannot
take full advantage of the technology in place to extend its
usage outside the campus. On the one hand, there is too
much incompatible software in the market; on the other,
there is a lack of state regulation on data storage and
exchange.
Portugal
SIS-ARD – information sys-
tem enabling eHealth interop-
erability in the Azores
SIS-ARD is an information system that integrates dif-
ferent IT systems of healthcare providers in the Azores.
In routine operation since 2007,it connects patients’elec-
tronic health records with a myriad of integrated mod-
ules containing clinical and non-clinical data.

SIS-ARD stands for Sistema de Informação da Saúde -

Açores Região Digital. It was developed in 2006 and went
into operation in 2007. This information system is a kind
of hub that links the electronic health records (EHR) of
patients with four main systems: firstly with a multi-
channel platform for health professionals and their
clients; secondly with the Electronic Resource Planning
(ERP) systems of hospitals and other healthcare organi-
sations; thirdly with the Integrated System of Health Unit Benefits
Management; and fourthly with the Integrated System of X Transparency and quality assurance: improved access
the Regional Health Service. to patients' data for healthcare professionals.
X Facilitated planning and management: linking different
The principle is roughly as follows: the Integrated System information systems provides better data for planning
of Health Unit Management is fed with data from the and management.
EHR, the ERP systems and the multi-channel platform. X Improved basis for research: the connection of different
This information, linked from different sources, facili- information systems facilitates data analysis.
tates planning and management processes in practically
all areas of health management, such as patient and hos- Lessons learned
pital management, the scheduling of consultations, and X Changes in workflows: the effective use of the system
the management of external entities. requires some adaptations in workflows; it takes time
to get the health professionals actively involved.
Patients can interact with the system through the multi- X Critical scope of the project: the wide span of system
channel platform. They can use telephone, internet, SMS integration was very ambitious; this requires risk assessment.
or eMail to access the system, using a Citizen Card for
authentication.

The SIS-ARD information system is expected to

strengthen team-orientation in healthcare provision.
Those involved are better connected, access to data is
facilitated, and data is more up-to-date.
41 ...
 Portugal
ePrescription at Coimbra
University Hospital
Coimbra University Hospital (HUC) in Portugal has
implemented an ePrescription scheme on the basis of the
"Integrated Management System of Medication Circuit"
(SGICM). This is a cycle consisting of three main ele-
ments: observation, decision, and prescription (action).
The SGICM ePrescription system implements this cycle,
including data on the actions of doctors, nurses and
pharmacists. The system became operational in 2003. It
improved the transparency of processes and created a
new culture of control and validation and, as a result, it
was possible to reduce the average number of prescrip-
tions per patient from 8.2 to 6.4.
... 42
INSA – improving
the quality of clinical tests
in decentralised sites
In 2006, the National Health Institute of Portugal (INSA)
introduced a web-based facility to improve the quality of
clinical tests and to speed up related processes. The appli-
cation allows laboratories on the mainland, the Azores,
Madeira and Macao to have their analytical performance
compared with reference labs. The participating institu-
tions can register for tests which INSA has scheduled,
submit their data and results online and analyse them
jointly with INSA. This initiative is part of a longer-term
quality assurance project launched by INSA in 2000.
Romania
DISPEC teletriage and
dispatch system – City
of Bucharest Ambulance
Service
DISPEC is a sophisticated ICT-enabled emergency ambu-
lance teletriage and dispatch system. It was specifical-
ly developed for the City of Bucharest Ambulance Service
(SAMB) in order to identify and allocate available ambu-
lances.

SAMB is a strategic medical unit in Bucharest providing

24 hour available medical emergency service. Rising
costs and tight budgets in the mid 1990s forced SAMB to
think of innovative ways to increase its productivity and
effectiveness. This led to the decision to develop DISPEC,
and the system was introduced in 1996. Prior to its imple-
mentation, a paper-based system had been used.
Emergency calls were received by untrained call-centre
operators who took notes on paper slips. Their notes
were (physically) taken to the coordinating physician
who, in turn, tried to identify and allocate the appropriate
resources with the help of radio operators.
By contrast, working with DISPEC means that trained
phone operators enter into the system information from
incoming emergency calls. The operator identifies the
nature and severity of the emergency directly with the
person reporting the incident and gives initial advice.
Then he or she attributes one of the four severity levels
for emergencies to a provisional diagnosis. Next, DISPEC
automatically generates the best match with the rescue
teams available, which are scattered all over the city area.
The radio operators allocate an ambulance equipped
with the appropriate facilities and staff and then direct
the teams to the emergency sites. In routine care, the
match is controlled by a coordinating physician. Time
savings are gained from a location reporting system
based on GPS (or global positioning system), which
allows operators to identify free ambulances nearest to
the location of the emergency.
DISPEC has had an important impact on response times:
today, ambulance arrival takes on average only a quarter
of the time needed in 1992. Efficiency gains resulting
from DISPEC enabled the ambulance service to cope
with increasing demand despite decreasing resource
availability during the late 1990s. After 2003, estimated
net economic benefits stabilised at a sustained level of
just over 1.4 million euro per year. DISPEC is entirely
funded by the Romanian Ministry of Health.
Benefits
X Faster response times: in 1992 the average response time
for all types of emergency calls was about 72 minutes
for an ambulance to arrive on site. After the implementation
of DISPEC this was reduced to an average of 24 minutes
in 1997 and 18 minutes today.
X Improved productivity: despite decreasing resources,
the ambulance service was able to cope with the increasing
demand.
X Cost savings: estimated net economic benefits have stabilised
at just over 1.4 million Euro per year since 2003. 43 ...
 Romania
Lessons learned
X Employing a local IT vendor was crucial for DISPEC’s success:
the service provider was familiar with the environment,
adaptive to sudden change – and affordable.
Clinical information system
for private clinics, Medicover
Romania and laboratories
Since 2004 seven Medicover clinics and nine Synevo lab-
oratories in Romania have employed a clinical informa-
tion system (CIS). Web-enabled applications allow the
streamlining of clinical processes such as referral man-
agement, patient invoicing and billing and operational
and managerial reporting, as well as the integration of
activities of related healthcare providers and laborato-
ries. Interoperability enables easy exchange of structured
documents between physicians, laboratories and CIS
clients.

Medical software at Dr. Victor

Babes Hospital, Bucharest
Medical software supports workflows at Dr. Victor Babes
Hospital in Bucharest. In routine operation since 2004,
the software links the various departments and integrates
pharmacy and laboratory applications. It provides easy
access to information on the patient flow, thus supporting
decision-making and administrative processes, and facil-
itates management of the hospital’s pharmacy stock.
Various reporting functions facilitate the processing and
analysis of stored medical information.

... 44
Slovakia
T3C – Tele-radiology
Communication Centre
The Tele-radiology Communication Centre T3C is cur-
rently used by 96% of all healthcare facilities using a
Picture Archiving and Communication System (PACS) in
the Slovak Republic. The exchange of imaging data
between Slovakian healthcare facilities and profes-
sionals has also been expanded to the Czech Republic.

T3C allows for the exchange of imaging data between

healthcare facilities and healthcare professionals in the
Slovak Republic as well as between the Slovak and Czech
Republic. This data exchange is possible between PACS
systems, stand-alone systems and stand-alone and PACS
systems. All data stored in DICOM standard (Digital
Imaging and Communications in Medicine) and all
health-related information may be sent and received
through T3C. Imaging data can thus be transferred to
and from all DICOM-compatible radiology and nuclear
medicine modalities, and structured reports and other
DICOM data can also be sent and received.An important
aspect addressed was the creation of a secure data Benefits
exchange encrypting system that ensures secure user X Faster and improved diagnostic processes due to enhanced access
identification and authorisation. to imaging information.

In routine operation since 2006, T3C has led to faster and Lessons learned
improved diagnostic processes, resulting in higher effec- X Interoperability was facilitated by using the DICOM standard
tiveness. Tele-counselling features are now possible with rather than connecting systems operating with many different
the help of the system. standards.

45 ...
 Slovenia
eDRG – web application for Benefits
X eDRG has set new standards for communication,
collecting, processing and security and interaction between hospitals and
analysing inpatient episodes the national data gathering centre in Slovenia.
X The implementation methodology and secure internet
eDRG is a web application implemented in 24 hospi- technology developed can be used for other nationwide
tals throughout Slovenia.The system supports the col- applications.
lection,processing and analysis of inpatient episodes in
XML format according to disease-related groups (DRGs) Lessons learned
at the hospitals and at a national data gathering cen- X Users have to be very disciplined with regard to accurate
tre. It went to routine operation in 2004. and on-time data input.
X eXtended Mark-up Language (XML) turned out
The eDRG application is a response to a challenge that all to be an appropriate data format.
national health systems are facing: to gather health data X Different levels of IT equipment, IT skills and technical
for purposes such as epidemiological studies, statistical support in the participating hospitals have
studies, reimbursement and the balancing and planning to be considered during implementation.
of financial expenses on a national level. In order to
establish a secure and reliable digital data exchange chan-
nel between the participating hospitals and the data gath-
ering centre at the national Public Health Institute, an
existing government communication network named
HKOM was used. Using eDRG, data on inpatient episodes
are collected every three months and transferred to the
data gathering centre. The centre processes and analyses
the data and provides the hospitals with feedback on the
results.

The system was co-funded by the Republic of Slovenia’s

Ministry of Health and Institute of Public Health,
through a World Bank project called Health Sector
Management Project. Upgrading, maintenance and sup-
port of the system is financed by the Institute for Public
Health.

... 46
Spain
Receta XXI –
ePrescribing in Andalusia
Receta XXI is an ePrescribing system used in the Spanish
region of Andalusia. It facilitates the prescription, con-
trol and dispensing of drugs as well as related billing
processes.The implementation of the system has had
a positive impact on the control of medication use
and expenses.

Receta XXI is built on three functional modules for: pre-

scriptions, dispensing and checking. When patients con-
sult a physician at a primary healthcare centre, they
present their electronic health card which contains their
identity as well as insurance status and rights profile. The
card enables the physician to access the Citizen Electronic
Health Record, which includes an electronic prescription
module. The physician uses this module to generate an
electronic prescription that is centrally registered in
Receta XXI. Patients can then go to any Andalusian phar-
macy with their healthcare identification card and the
pharmacist can check the prescription online and dis-
pense the prescribed drug. In the case of a contraindica-
tion, the pharmacists will not dispense the medication,
but leave a message for the attending practitioner.
Receta XXI brings benefits for all stakeholders involved.
For example, GPs can issue long-term prescriptions for
chronically ill patients for a period of up to one year. This
releases both patients and physicians from the burden of
repeated consultations for prescription renewal only. For
pharmacies, Receta XXI facilitates stock control and
administrative processes, as it is interconnected with the
pharmacy management system and with the General
Pharmaceutical Council system for billing and account-
ing services. Receta XXI became operational in 2003. In
2007, it was implemented in 28% of around 1,500 pri-
mary healthcare centres and nearly 90% of approximate-
ly 3,500 pharmacies in the region. The system is entirely
funded by the Andalusian Health Service.
Benefits
X Convenience for patients: long-term prescriptions have
reduced the number of visits of chronically ill patients
by 22%.
X Improved control mechanisms: ePrescription
of drugs via electronic health cards facilitates
checks for contraindications.
X Improved process efficiency: the integrated data flow
from prescribing to delivery simplifies administrative
tasks and reduces costs.
Lessons learned
X Information requirements: educating users of the system
required a substantial amount of effort.
X Need for change management: changing traditional work
processes can meet resistance, even if the benefits are clear.
X The complexity of the relationships between the
stakeholders involved (physicians, pharmacists, the
Pharmacists' Professional Organisation, other healthcare
organisations, patients) has to be considered.

12 ...
47
 Spain
Diraya – the electronic health
record system of Andalusia
Diraya is a health information system in the Andalusian
region of Spain. It currently covers primary care, outpa-
tient specialised care and emergency care services and
integrates the health records of 6.7 million citizens. Since
its rollout in 2003 different modules have been gradually
integrated into the system, such as for appointments,
electronic health records and ePrescribing. Patients are
registered with Diraya with a unique identification num-
ber. The system allows the patients’ data to be synthesised
and viewed as a single electronic health record.
Imaging network project,
Valencia
The Imaging Network project aims to develop a fully
interoperable digital imaging system connecting 27 hos-
pitals and around 900 primary care centres in the region
of Valencia, Spain. The approach is to connect radio-
diagnostic services with hospital information systems
(HIS) and radiology information systems (RIS). Once
fully established (roll-out is in process), the network is
expected to improve diagnoses by enabling groups of
specialists to view images simultaneously. It may also
reduce repeated hospital visits by improving information
flows between providers.
TmAPEx – Telemedicine
Network for Primary Care
in Extremadura
The Telemedicine Network for Primary Care in
Extremadura (TmAPEx) enables primary care centres in
rural areas to consult with specialists in distant reference
hospitals. This improves their diagnostic capacity and
saves patients' time and money, avoiding long-distance
travel to hospitals. Evaluations for two participating pen-
... 48 itentiary centres in 2007 showed that the number of visits
to reference hospitals was reduced by 50%. Consultations
can be in real time (via videoconferencing) or deferred;
real time consultations account for close to 90% of cases.
Ykonos – immediate access to
radiological clinical informa-
tion and medical images
Ykonos is a regional digital imaging network in the
region of Castilla-La Mancha, Spain. Through Ykonos,
health professionals can access the radiological informa-
tion and medical images of any patient. Radiological
images are digitised and stored in an integrated system
through PACS (Picture Archiving and Communication
System) and RIS (Radiology Information System). The
network comprises 18 hospitals, ten centres of specialised
diagnosis and treatment, eight primary care centres and a
virtual teleradiology centre. The costs of establishing
Ykonos amounted to about 20 million euro (2003-2007),
while 15 million euro are budgeted for the period 2008-
2012.
Paperless and filmless
healthcare at Son Llàtzer
Hospital, Palma de Mallorca
Son Llàtzer Hospital in Palma de Mallorca is an example
of a paperless and filmless hospital where almost all pro-
cedures are undertaken electronically. Online applica-
tions comprise all departments, professionals, processes
and tasks. The medical workstation is the core unit of the
system architecture, allowing the health professionals to
access the clinical history of a patient as well as related
clinical and administrative data. Patient data can also be
processed through wireless portable tablet computers
and Personal Digital Assistants.
Sweden
Klamydia.se – fighting
the spread of sexually
transmitted diseases
Via the Swedish website Klamydia.se, citizens can
order a Chlamydia test package free of charge and access
their laboratory results – without having to visit a clin-
ic to test whether they are infected.The convenience and
anonymity of the procedure results in an increased num-
ber of people getting tested and (if infected) treated –
thus counteracting a further spread of this sexually trans-
mitted disease.

Chlamydia, caused by the bacterium Chlamydia tra-

chomatis, is one of the most common sexually transmit-
ted infections worldwide. It is highly contagious and can
affect both males and females; it can also be passed from
an infected mother to her baby during childbirth. The
number of cases of infection has been increasing in
recent years. Infected people often have no symptoms
and therefore do not know that they are infected. Left
untreated, however, Chlamydia can cause severe prob-
lems and lead to infertility. Against this background,
Klamydia.se was introduced in an attempt to counteract
its further spread and to gather more information on the
disease.
Residents of four Swedish counties can, if they suspect an
infection, visit www.klamydia.se and order a free person-
al test package. Upon completion of the test, users return
an envelope containing a urine sample to the laboratory.
They are informed by e-mail when their test results are
available. Results can be accessed at the klamydia.se web-
site by entering a personal code, which is created for each
test individually and will never be revealed. If the user
does not check his/her results after one week, a reminder
will be sent. If the results are negative, the case is closed
and all personal information about the test person is
deleted. If the person is infected, she or he will be
informed accordingly and reminded that treatment is
mandatory by law. In this case, the person’s file will not be
closed until she or he consults a physician, who will then
in turn inform klamydia.se that treatment has started. If a
Chlamydia positive-tested person fails to seek medical
attention within two weeks of obtaining positive test
results, the database will send a final reminder to do so. If
this final attempt fails, the case will be referred to the local
centre for disease control.
Klamydia.se started in Västerbotten County in 2004 as a
joint project of the Institute for Public Health and Clinical
Medicine and the Institution for Clinical Microbiology at
Umeå University, funded by the National Institute for
Public Health. In 2006, it was implemented in the Västra
Götland region by the Department of Communicable
Disease Control.
First evaluation results indicate positive impacts both in
terms of healthcare and costs. The opportunity of con-
ducting the test anonymously at home (and free of
charge) reduces barriers for people being tested for
Chlamydia. In a survey among 230 users of the service in
October 2007, 73% said that they would either not have
sought immediate and proper testing or would not have 49 ...
 Sweden
been tested at all if the online service had not been avail-
able. About 14,300 tests were conducted via klamydia.se
between September 2004 and October 2007. 7.3% of
those were positive. Pushing the treatment of people cur-
rently infected with Chlamydia is key to preventing the
further spread of the disease and thus, eventually, achiev-
ing a decline in the number of new infections. On the cost
side, the web-based procedure of the testing leads to cost
savings. While the council has to pay 160 Euro for each
visit to an STI clinic, a test ordered via klamydia.se costs
only about 20 Euro. A further positive effect is that the
data collected through the initiative is a valuable source
for research in the field of sexually transmitted infections.
The project had to cope with some challenges, such as
developing the logistics solutions for the medical test lab-
oratories involved. Another challenge was to convincing-
ly demonstrate the "business case" for healthcare
providers prior to the start of the project, i.e. the positive
effects and long term gains which the application promis-
es to deliver. Finally, conflicts of interest had to be
addressed, as the internet-based testing procedure was
seen to be in competition with existing services.
ACTION – assisting carers
using telematics interventions
to meet older people’s needs
ACTION is a home care service currently available in
eight Swedish municipalities. It aims to maintain and
enhance the autonomy and quality of life of frail and dis-
abled people and their (non-professional) family carers
by providing information, advice and support in the
home. There is a local ACTION call centre in each of the
municipalities, manned by nurses and aid consultants to
the family-carers. Subscribers are provided with a video-
phone which can be used for communicating with the
nurses and other ACTION families. ACTION started as a
3-year EU-funded research project (1997-2000) and
became operational in 2004.

Benefits
X Increase in people getting tested for Chlamydia:
the anonymity of the web-based procedure reduces
barriers for getting tested: 25% of users say they would
not have taken a test otherwise.
X Cost savings: a test conducted via klamydia.se costs
the Council 20 Euro compared to 160 Euro
for a test conducted in a clinic.
X New data: improved empirical evidence for research on STIs.

Lessons learned
X The logistics of sending out a huge number of laboratory
tests must be carefully planned.
X Some conflicts of interest must be anticipated;
the web-based procedure competes to some extent
with existing healthcare services.

... 50
Sweden
Sjunet – teleradiology
consultations between Sweden
and Spain
Several hospitals in Sweden face a shortage of radiolo-
gists. Teleradiology can be the solution to this problem, as
it enables radiology departments in different hospitals to
connect and thus to provide services to each other. The
hospitals of Sollefteå and Borås use Sjunet, the Swedish
ICT network for healthcare teleradiology, to co-operate
with radiologists located in Spain. The model is used for
non-emergency examinations. After skilled radiology
nurses have conducted the magnetic resonance imaging
(MRI) in the Swedish hospital, the images are sent via
Sjunet to the Telemedicine Clinic in Barcelona for analy-
sis - the results arrive typically within 24-48 hours. Borås
also sends computed tomography images. The service
was introduced in 2003 and since then, the waiting time
for MRI scans has been reduced by half.

Apoteket – ePrescribing
Currently 42% of all prescriptions in Sweden are trans-
ferred electronically from doctor to pharmacy via Sjunet,
the Swedish ICT network for healthcare. The digitisation
was enabled by a joint effort between each county council
in Sweden and Apoteket, Sweden’s national pharmacy.
The prescription can either be sent to a specific pharma-
cy or to a national mailbox, which allows all 900 pharma-
cies in Sweden to pick up a prescription so that patients
do not have to specify in advance where they want to col-
lect the medicine. Technically, XML and Edifact are both
used as standards for the message exchange in the pre-
scribing process. A cost-benefit assessment of the service
for the Stockholm County estimated that the annual net
economic benefit of ePrescribing amounted to over 95
million euro in 2008.

51 ...
 Switzerland
Computerised patient record
systems at the University
Hospitals of Geneva
The clinical information system (CIS) at the University
Hospitals of Geneva (HUG) illustrates in a profound
way what electronic health records, combined with
ePrescribing in a wider sense, can do for healthcare
provision in a hospital environment.
HUG is a consortium of seven hospitals and more than
30 ambulatory facilities in the Swiss state of Geneva.
HUG manages over 48,000 admissions and 800,000 out-
patient visits each year, with a base of more than 2,000
beds and over 7,000 care professionals. Since 2000, a uni-
fied and shared patient-centred CIS is used in the com-
plete HUG running on more than 7,000 PCs. More than
25,000 records are open every day, seven days a week,
around the clock, with never less than 500 records
accessed each hour. The system serves 3,000 care
providers, including physicians, nurses, medical secre-
taries, social care providers and physiotherapists.
The CIS is mainly an in-house development. It is compo-
nent-based with a message-oriented middleware distrib-
uted system. Several components or clinical systems,
such as the Picture Archiving and Communication
System (PACS), are industrial solutions that have been
integrated into the CIS. Numerous interfaces, extracting
data from different databases, have been built in order to
allow customised viewing of data according to providers’
needs and wants.
The CIS is patient- and user-centred in its input and out-
put elements. Queries are managed according to access
rights and interfaces based on the clinical role of the per-
son performing the query, and are always restricted to a
specific patient.
The system has links with private laboratories in order to
... 52 receive lab results from outside the consortium. The
records in the system, including lab results, reports, pre-
scriptions and images, can be sent electronically to exter-
nal addressees, such as private hospitals and general
practitioner practices using a secured and authenticated
network. Integration with other systems is planned.
The Computerised Patient Records (CPR) comprises
administrative information, unified clinical documenta-
tion, order entry for all orders in ATC encoding (e.g. lab,
drug, radiology, care), imaging in DICOM standard, lab-
oratory, admission, discharge, and transfer information
according to the HL7 RIM model. Clinical and nursing
documentation are stored as 12 million documents as
well as 130 million structured facts. There are over 13,600
document type categories, so the CPR is used for many
other purposes than care, such as admission administra-
tion, billing, resource management, epidemiology, and
clinical research.
Interoperability is a fundamental requirement. As all
components are completely independent and can only
communicate through standardised http/XML services
or standardised XML messages, a common framework of
protocols and semantic formalisations has to be used.
Most of this has been achieved using existing standards
whenever possible.
The system came into use in 2000. The cumulative break-
even from a socio-economic perspective was achieved in
2007 at some 60 million Swiss Francs. By 2009, the value
of annual benefits is expected to be more than twice the
value of annual costs.
Switzerland
Benefits
X Improved quality of care and patient safety, stemming
from better informed decisions by care providers and
various decision support features such as alerts and
clinical pathways.
X Longer-term cost savings: by 2009, the estimated value of
annual benefits is expected to be more than twice the value
of annual costs.

Lessons learned
X Generation gap: older people took longer to accept and
adapt, sometimes needing to learn some computer basics
first.Younger people were more likely to be comfortable
with computers.
X Selected use: doctors and nurses at HUG acknowledge that
they do not use most of the functionalities of the CIS and
need to learn more about what the system can do and how.
X Unexpected patterns of uptake: the CIS led to rapid increases
related to new recruitment from the university’s medical
faculty.

Medgate – Swiss centre

for telemedicine
Since its foundation in 1999, Medgate has become the
leading Swiss centre for telecounselling (doctor to doc-
tor) and teleconsultation (patient to doctor). More con-
ventional centres only provide information to the patient.
In contrast, Medgate can in 57% of all patient contacts
successfully treat the patient and prescribe medicine via a
mail-order pharmacy. A team of 90 physicians and med-
ical assistants handles 2,000 patient contacts daily and
takes care of around 2.8 million insured persons via tele-
phone, internet and biometric monitoring.

53 ...
 Turkey
GCIS – Turkish Green Card
Information System
In Turkey,the healthcare of citizens without social insur-
ance is covered by a Green Card (GC) system.Since 2005,
the records of GC holders and potential GC obtainers
have been stored centrally in a GC Information System
(GCIS).This system has significantly facilitated approval
procedures for obtaining health services – a process that
used to be paper-based before the GCIS was introduced.
The GCIS is a web-based system for managing health
records and applications for health services. Prior to the
implementation of the GCIS, Green Cards were distrib-
uted by local administration, and the related data was
stored only locally and in paper-based format. This creat-
ed problems whenever GC holders requested medical
services at a location other than where they were regis-
tered. To address this problem, the Turkish Ministry of
Health decided in 2004 to implement a central database
where all GC holders would be recorded. The system
became operational in 2005 and since then, more than 12
million records have been stored in this central reposito-
ry. Approval procedures for providing health services to
GC holders have become much more efficient; paper-
work and the related administrative burdens have been
significantly reduced.
The GCIS is also a tool for e-administration, as it facili-
tates the sharing of data between different government
institutions and agencies. The database provides a single
interface to the government software systems. For exam-
ple, GCIS data is shared between the regional Green Card
offices and the Population Administration Directorates,
and with the Pension Fund General Directorate. The gov-
ernment also uses the data for socio-economic research
and analysis purposes.
... 54
Benefits
X Improved health service coverage and reduced
administrative burdens for Green Card holders:
the GCIS facilitates and accelerates approval procedures
for obtaining health services.
X Enabling tool for e-administration: the information system
facilitates data sharing between different government
institutions and agencies.
X Tool for analysis: the database facilitates the provision
of health statistics and of socio-economic indicators.
Lessons learned
X Project implementation takes time: the time needed
to set up and implement a central information system
should not be underestimated.
X Capacity planning is important: the GCIS has to cope
with a huge amount of data flowing into the system.
It is important to anticipate capacity requirements.
FMIS – Family Medicine
Information System for
Turkey
The "Family Medicine Information System" (FMIS) is
used by general practitioners to store their patients’
health service records. Data is stored locally and then
transferred to a central electronic health record (EHR)
database located at the Ministry of Health. This central
EHR database enables the production of national health
statistics in an efficient way. FMIS also facilitates the ret-
rospective and introspective analysis of health data and
referrals between primary and secondary care services.
Interfaces are compliant with the Health Level 7 (HL7)
standard, version 3.
United Kingdom
Choose and Book – in West
Essex Primary Care Trust
Choose and Book is a national solution of the National
Health Service (NHS) which combines electronic book-
ing and patient choice. In the Harlow locality, all ten
GP practices serving a population of about 87,000 are
now operating the service effectively to support patient
choice.

The objective of Choose and Book is to allow the patient

to book his or her appointment at the most appropriate
time and date in order to reduce the number of appoint-
ments where patients do not attend. It enables a more
flexible and responsive healthcare service, fitting around
people’s individual lives. Furthermore, appointments are
booked electronically to reduce time spent by healthcare
professionals on referral appointments and to improve
the security and confidentiality of patient data trans-
ferred between different healthcare institutions.
All ten GP practices in the Harlow locality, serving a pop-
ulation of 87,145, are now operating the service effective-
ly to support patient choice. This means that, since
January 2006, patients referred by their GP to a specialist
are able to choose from at least four hospitals or other
healthcare providers commissioned by their Primary
Care Trust. By calling the Choose and Book Appointment
Line or www.nhs.uk, they receive information about
healthcare providers. Based on this information, they
choose a provider and book their appointment through
the internet, the Appointment Line or via their GP prac-
tice. Patients are issued with guidance on how to book
appointments at the point of referral.
Choose and Book was developed nationally as part of
Connecting for Health, an agency of the Department of
Health supporting the NHS to introduce new computer
systems and services. The initial requirement focused on
a simple electronic referral system based on e-mail, with
no real-time, multi-channel connectivity.When the func-
tionality for choice was added, a web-based booking sys-
tem was required to operate with several different ICT
facilities in hospitals and GP practices. Choose and Book
complies with N3, the NHSmail secure email system for
the National Health Service, National NHSiS Clinical
Data Standards, National ICT Security Standards and
Policy and the National Framework Contracts for
Hardware Provision.

55 ...
 United Kingdom
Benefits
X Increased convenience to patients: appointments and
admissions are made in consultation with the patients
in order to find a suitable date and time for both parties.
X Increased feeling of certainty: prompt electronic
appointment booking provides patients with more
and immediate certainty.
X Time and cost savings due to a reduction of
the administrative burden.
X More effective management of referrals.
Lessons learned
X Resistance to process change: continued use of traditional
appointment process by GPs, consultants and other staff
slows down uptake of the service.
X Overreliance on piloting was found
to defer benefits realisation.
ePharmacy at Chelsea and
Westminster Hospital
The ePharmacy system at the Chelsea and Westminster
Hospital in London includes electronic prescribing, dis-
pensing, distribution, stockmanagement, and procurement
of drugs. 65% of all dispensary transactions are performed
by a dispensing robot. The robot is provided with the infor-
mation for each prescription. It then picks the items from
stocks and either transfers them to the dispensary staff for
dispatch to wards,or hands them to the appropriate patients
waiting at the dispensary. The system warns prescribers if
prescribing a medicine that interacts negatively with anoth-
er, or when the patient is allergic to a medicine.
Development of an electronic
patient record at Homerton
and Newham hospitals
In 2004 Homerton and Newham, two NHS hospitals in
London, jointly implemented an Electronic Patient
Record (EPR) solution with several exceptional modules,
... 56 such as an accident and emergency patient pathway, a
maternity services record, and a patient administration
system with booking and waiting lists management. The
hospitals use the EPR to work collaboratively across sev-
eral specialities. Having a shared solution for two hospi-
tals required meticulous process mapping.
Scottish ambulance
communication solutions
Scottish Ambulance uses innovative eHealth services
such as cab-based mobile data transmission, access to the
patient community health index, telemetry and telemed-
icine. The cab-based terminals system links front line
ambulance crew with two mobile data terminals to the
command and control systems. One terminal deals with
incident messaging, satellite navigation and mapping.
The other deals with electronic patient records and access
to emergency care summaries, standard operating proce-
dures and clinical databases. As of 2007, all ambulances
were equipped with terminals.
NHS Direct Online
NHS Direct Online (NHSDO) is a web portal offering
information about health and healthcare. The service is
complementary to the NHS Direct call centres, which
focus more on symptomatic response to users. The portal
offers a health information enquiry service, a health ency-
clopaedia, a best treatments website, self-help guide,
details of local NHS services and various interactive tools.
The number of visitors to NHSDO has risen from about
1.5 million in 2000 to some 24 million in 2008 (forecast).
NHS Scotland Emergency
Care Summary
The NHS Scotland Emergency Care Summary (ECS)
system provides a summary of demographic, allergy and
medication information for patients in Scotland from GP
practices. The ECS enables out-of-hours, A&E, and the
national call centre clinicians’ access to important patient
information in emergency care situations.
European Commission
Luxembourg: Office for Official Publications
of the European Communities
2009 —60 pp. — 21 x 29.7 cm
ISBN-13 978-92-79-11138-9
Catalogue number: KK-80-09-452-EN-C

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